Solid Ground Intake Form
Standard online intake form based on the analyzed PDF. Fields are optional unless marked required in the original document.
Applicant Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts
Emergency Contact #1 First Name
*
Emergency Contact #1 Last Name
*
Emergency Contact #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2 First Name
*
Emergency Contact #2 Last Name
*
Emergency Contact #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal and Supervision Status
Are you a convicted felon?
*
Yes
No
If yes, please describe the charge
Do you have any pending cases?
*
Yes
No
Are you currently on probation?
*
Yes
No
Health and Care Needs
Psychiatric Conditions
Current
History Of
Not Applicable
Addiction Disorders
Current
History Of
Not Applicable
Medical Conditions
Current
History Of
Not Applicable
Trauma / Abuse
Current
History Of
Not Applicable
Prescribed Medications
Current
History Of
Not Applicable
Current Health Problems
Current Medications
Can they independently complete daily living activities?
*
Yes
No
Do they require medical supervision or personal care assistance?
*
Yes
No
Are they currently struggling with active substance abuse?
*
Yes
No
If in recovery, how long have they been sober?
Substance Use History
Substance #1 - Drug Type
*
Please Select
Alcohol
Cannabis
Opioids
Stimulants
Benzodiazepines
Hallucinogens
Nicotine
Other
Substance #1 - Method
Please Select
Oral
Smoke
Inhale
Inject
Snort
Topical
Other
Substance #1 - Last Use
-
Month
-
Day
Year
Date
Substance #1 - Age at First Use
Substance #2 - Drug Type
Please Select
Alcohol
Cannabis
Opioids
Stimulants
Benzodiazepines
Hallucinogens
Nicotine
Other
Substance #2 - Method
Please Select
Oral
Smoke
Inhale
Inject
Snort
Topical
Other
Substance #2 - Last Use
-
Month
-
Day
Year
Date
Substance #2 - Age at First Use
Substance #3 - Drug Type
Please Select
Alcohol
Cannabis
Opioids
Stimulants
Benzodiazepines
Hallucinogens
Nicotine
Other
Substance #3 - Method
Please Select
Oral
Smoke
Inhale
Inject
Snort
Topical
Other
Substance #3 - Last Use
-
Month
-
Day
Year
Date
Substance #3 - Age at First Use
Income and Benefits
Principal Source of Income
*
None
Salary
Public Assistance
Disability
Retirement
Monthly Income Amount
*
Number of Dependents
Benefits Received
Medical
SNAP
SSD/SSI
Other
Medicaid Status
Please Select
Active
Not Active
Pending
Unknown
Support Services and Referral
Currently working with an agency, case manager, or sponsor?
*
Yes
No
Agency / case manager / sponsor name
Agency / case manager / sponsor phone number
May we contact them? Please explain any limits or preferences.
Who referred you to Solid Ground Independent Living?
*
Please Select
Self
Treatment Center
Nursing Facility
Probation/Parole
Other
Referring company name
Referring company street address
Referring company city, state/province, postal/zip code
Housing Situation and Program Fit
Where are you coming from?
*
Please Select
Private Residence
Residential Care / Treatment
Hospital
Prison / Jail
Homeless
Temporary Shelter
Other
Reason for leaving
*
Have you been homeless within the last six months?
*
Yes
No
Are you at risk of homelessness?
*
Yes
No
Have you lived in a shared home setting before?
*
Yes
No
If yes, when did you last stay in a shared home setting?
*
What assistance do you need?
*
Housing
Medical Care
Education
Cleaning
Mental Health Services
Employment Support
Transportation
Food Assistance
Financial Counseling
Life Skills Coaching
Childcare
Legal Assistance
Other
Are you okay with sharing a double-occupancy room?
*
Yes
No
Other
Can you pay four weeks or one month's rent upfront?
*
Yes
No
Other
Can you pay a one-time, non-refundable move-in / move-out / key set-up fee?
*
Yes
No
Other
Do you plan on staying for at least 3 months?
*
Yes
No
Other
Additional Information and Consent
Anything else you would like for us to know?
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: