Intake/Pre-Screening Form
Please provide your details to complete the intake process.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where were you referred from?
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INCOME & BENEFITS:
Do you have steady/verifiable income?
YES
NO
What is your main source of income?
SSI (Supplemental Security Income)
SSDI (Social Security Disability Income)
Employment
VA Benefits
Other
What is your estimated monthly income? (We may ask to verify. Proof can be shown in person or electronically.)
Do you receive Food Stamps/ EBT (SNAP benefits?)
YES
NO
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INDEPENDENT LIVING ABILITY:
Are you able to live independently without daily assistance?
YES
NO
Are you currently taking any medications?
YES
NO
Do you have any difficulty accessing your medication? If so, explain.
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HOUSING PREFERENCES & NEEDS:
What kind of room are you looking for?
Shared Room
Private Room
No Preference
When do you need housing? (Move in date)
Do you have any physical disability or mobility concerns?
YES
NO
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BACKROUND & SCREENING:
Have you ever been convicted of a felony?
YES
NO
Are you registered sex offender?
YES
NO
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LIFESTYLE & HOUSE RULES:
Are you willing to follow house rules? (e.g., No drugs, No Unapproved guest, quiet hours, cleanliness)?
YES
NO
Do you smoke?
YES
NO
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FINAL NOTES:
Why are you seeking housing at this time?
What are your current living arrangements?
Is there anything else you'd like us to know?
Submit
Should be Empty: