Group Home Housing Application Form

Resident Intake Application

Complete this form to apply for housing at our group home. Please have your information ready and review the instructions.
Applicant Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender

Other
Preferred Pronouns
Representative/Guardian Information
Does the applicant have a legal guardian or representative?
Guardian/Representative Name

First NameLast Name
Guardian/Representative Relationship
Guardian/Representative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian/Representative Email Address
example@example.com
Health Information
Primary Diagnosis
Secondary Diagnoses (if any)
Allergies
Current Medications

Assistance with Activities of Daily Living (ADLs)

Substance Use History
Has the applicant ever used substances (alcohol, drugs, tobacco)?
If yes, please describe substances used and dates (if applicable)
Legal History
Has the applicant ever been convicted of a crime?
If yes, please describe the offense(s) and dates
Is the applicant currently on probation or parole?
Financial Information
Primary Source of Income
Monthly Income (USD)
Does the applicant have a payee?
Support Team Contacts
Case Manager Name

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager Email
example@example.com
Therapist/Clinician Name

First NameLast Name
Therapist/Clinician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Therapist/Clinician Email
example@example.com
Other Support Team Members (names and roles)
Decision Maker
Who is the primary decision maker for the applicant?

Other
Housing History
Has the applicant previously lived in a group home?
If yes, please list previous group home(s) and dates
Reason for leaving previous housing
Compatibility
Preferred roommate characteristics (check all that apply)

Other

Please rate the importance of each roommate characteristic

Resident Intake Application