• Supportive Housing Intake Assessment

    Please complete this form to help us understand your housing needs and eligibility for supportive housing services.

  • Referral Information

     

  • Format: (000) 000-0000.
  • Member Referral Reason
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Member Information

  • Gender*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Identification (provide original at intake)
  • Income verification
  • Have you ever had an eviction?*
  • Can you consent to a criminal background check?*
  • Are you currently on Probation or Parole?*
  • Are you comfortable living in a structured shared home with restrictions?*
  • Are you comfortable with keeping the home safe and clean?*
  • Do you have any medical or mental health conditions staff should know about in case of an emergency?*
  • Currently prescribed medications?*
  • Have you ever used marijuana or any other drugs?*
  • Are you a smoker?*
  • Do you have alcohol abuse?
  • Are you currently experiencing housing instability or homelessness?*
  • What type of room does the client prefer*
  • Do you suffer from any mental illness?*
  • Have you ever been arrested?*
  • Do you have a service animal or pet?*

  • I understand this is a program participation arrangement, not a traditional lease or tenancy. I understand participation requires compliance with program rules, house expectations, and community standards.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: