Supportive Housing Client Intake Form
Complete this intake form for review.
Participant Intake & Enrollment Application
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Social Security Number (Last 4 Digits)
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Gender
*
Male
Female
Non-binary
Prefer not to say
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
Current living situation
*
Homeless
Couchsurfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
If other, please specify
Referral Source
*
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Referring Contact Name
Medical & Mental Health History
List any current or past medical conditions
Mental health diagnosis
Substance use history
Alcohol
Drugs
None
Please explain your substance use history
Legal Background
Currently on parole or probation?
*
Yes
No
Parole or probation officer name and phone number
Registered sex offender?
*
Yes
No
Income Information
Do you have a source of income?
*
Yes
No
Income sources
*
SSI
SSDI
Employment
Other
Monthly income amount
*
Housing Preferences or Needs
Any disabilities or accommodations needed?
*
Yes
No
Please explain any disabilities or accommodations needed
Preferred Room Type
*
Please Select
Semi Private-Shared Room
Private Room
Independent Living & Functionality Acknowledgment
Program conditions
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
Explanation
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Agency Name
Acknowledgment statement
Participant Initials
*
Date
*
-
Month
-
Day
Year
Date
Program Agreement Preview
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins
*
I agree
I acknowledge that violating rules may result in a strike or dismissal from the program
*
I acknowledge
Applicant Declaration
Certification Statement
Participant Name
*
First Name
Middle Name
Last Name
Participant Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
Should be Empty: