Belle Halo Housing Solutions Intake Form
Please complete this intake form to help us understand your needs and eligibility for our transitional housing program.
Full Legal Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender Identity
Male
Female
Transgender
Other
Gender Identity - Other
Are you a Veteran?
Yes
No
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Any Criminal Conviction
Yes
No
County of Conviction
Conviction(s) Description
Parole / Probation Status
Yes
No
Parole/Probation Contact Name
Parole/Probation Contact Information
Seeking Transitional Housing Placement
Yes
No
Housing Restrictions (e.g., due to charges)
Yes
No
If Housing Restrictions, Explain
Highest Level of Education Completed
Please Select
Less than High School
GED
High School Diploma
Some College
Associate’s
Bachelor’s
Graduate
Other
Highest Education - Other
Total Time Worked in Lifetime
Type of Employment / Skills / Experience
Chronic Medical Conditions
Yes
No
If Chronic Medical Conditions, Specify
Currently Taking Prescribed Medications
Yes
No
List Medications and Dosages
Allergies
Yes
No
If Allergies, Specify
Date of Last Physical Exam
-
Month
-
Day
Year
Date
Diagnosed Mental Health Condition
Yes
No
If Mental Health Condition, Specify
Currently Receiving Mental Health Treatment or Counseling
Yes
No
If Receiving Mental Health Treatment, Where
History of Substance Use or Addiction
Yes
No
Describe Substance Use History and Current Recovery Status
Currently Enrolled in or Seeking Substance Abuse Treatment
Yes
No
Immediate Needs After Release
Housing
Mental Health Services
Medical Care
Identification / Documents
Transportation
Employment
Food
Clothing
Other
Immediate Needs - Other
Short-Term Goals (next 3–6 months)
Require Assistance with Activities of Daily Living (ADLs)
Yes
No
Use Mobility Aids
Yes
No
Can Manage Own Medications
Yes
No
Can Manage Own Money
Yes
No
Can Prepare Own Meals
Yes
No
Can Perform Household Chores
Yes
No
Cognitive or Memory Impairments
Yes
No
If Cognitive or Memory Impairments, Specify
Experienced Behavioral Outbursts or Aggression
Yes
No
Willing to Follow House Rules and Program Guidelines
Yes
No
Substance Abuse/Addiction History (Behavioral Screening)
Yes
No
Currently Using Illegal Substances or Alcohol
Yes
No
Ever Involved in Behavioral or Anger Management Programs
Yes
No
Understands Smoking Rules (OUTSIDE ONLY)
Yes
No
Understands Shared Living Environment
Yes
No
Understands Cleanliness and Personal Responsibility Expectations
Yes
No
Understands This Is Not a Medical or Nursing Facility
Yes
No
Understands This Is Not a Mental Health Treatment Facility
Yes
No
Understands No Personal Care or Home Health Services Provided
Yes
No
Understands Medications Are Not Managed by Facility
Yes
No
Understands 30-Day Notice Required Before Moving Out
Yes
No
Required Documentation - State ID or Driver’s License
Provided
Required Documentation - Social Security Card
Provided
Required Documentation - Proof of Income
Provided
Required Documentation - Medical Records (if applicable)
Provided
Required Documentation - Parole/Probation Papers (if applicable)
Provided
Required Documentation - Other
Consent and Acknowledgment
Client Printed Name
Client Signature
Date Signed
-
Month
-
Day
Year
Date
Submit Intake Form
Submit Intake Form
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