Housing Intake
Standard online housing intake form based on Housing Intake.docx. Complete the fields in order and use the exact field types and options provided.
Intake and Contact Information
Date of Intake
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Move in date pending approval
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Agency/Name of Referrer
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Please Select
Male
Female
Non-binary
Prefer not to say
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
Homeless
Couchsurfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
Are you aware this is a shared living space, shared with others?
Referral Source
*
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Walking Aides
*
Walker
Rollator
Cane
Wheelchair
Housing Need and Background
Brief Summary of Situation / Reason for Housing Need
*
Medical & Mental Health History
*
Mental Health Diagnosis
*
Substance Use History Or Current
*
Alcohol
Drugs
None
Currently
Previously
Substance Use History - If yes, explain
Currently on Parole or Probation
*
Yes
No
Parole/Probation Officer Name and Phone Number
Registered Sex Offender
*
Yes
No
Do you have a source of income?
*
Yes
No
Income Source Type
SSI
SSDI
Employment
Other
Any disabilities or accommodations needed?
*
Yes
No
Able to walk up and down a full flight of stairs
If yes, describe disabilities or accommodations needed
Preferred Room Type
*
Shared Room
Private Room (if available)
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
If no, please explain your ADL support needs
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Home Health Care / Support Service Agency Name
Participant and Staff Acknowledgment
Participant Initials
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Name
*
Participant Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Name
Staff Signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: