Intake Form

Intake Form

Complete this intake form using the reference PDF as the authoritative source for labels, order, and field mapping.
Applicant Contact and Identification
Date

MonthDayYear
Date
Full Name

First NameMiddle NameLast Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email
example@example.com
Government-issued ID status
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Supervision and Legal Status
Highest level of supervision
Parole/Probation Officer Name
Parole/Probation Officer Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Any active restraining orders or history of arson or violent crimes
Registered as a sex offender
Upcoming mandatory court dates
Housing Need and Daily Functioning
Current situation
What brought you to needing housing right now
What does a typical day look like for you
Have you ever lived in shared housing before
What do you need help with the most
Are you comfortable with rules, curfews, and structure
How do you handle disagreements or stress
Maintained continuous sobriety for the last 30 days
Can perform all Activities of Daily Living (ADLs) unassisted
Any physical mobility restrictions requiring a first-floor room
If yes, specify mobility restrictions
Housing History and Financial Resources
Have you ever been evicted? If yes, please explain why.
Current active housing voucher or rental assistance
Voucher or program ID number
Current income source
Current income amount
Employer
Employer contact telephone
Please enter a valid phone number.Format: (000) 000-0000.
Currently employed - work schedule
If not employed, what is your plan for financial sustainability?
Treatment, Medical, and Support Information
Engaged in outpatient counseling or substance use treatment programs
Program
Medical or Mental health conditions requiring reasonable accommodations
Current Medications
Emergency contact name
Emergency contact telephone
Please enter a valid phone number.Format: (000) 000-0000.
Case worker Name
Case worker contact telephone
Please enter a valid phone number.Format: (000) 000-0000.
History of conflicts with specific individuals in the community
Conflicts details
Support system (Family Member or Mentor or Case Worker)
Certification and Signature
Resident printed name
Resident signature
Signature date

MonthDayYear
Date
Should be Empty:

Intake Form

Applicant Contact and Identification

Supervision and Legal Status

Housing Need and Daily Functioning

Housing History and Financial Resources

Treatment, Medical, and Support Information

Certification and Signature