Supportive Housing Client Intake Form
Participant Intake & Enrollment Application
Client Information
Date of Intake
*
-
Month
-
Day
Year
Date
Referral Information
How were you referred?
*
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Other
Referring Agency
Referring Contact Name
Referring Contact Phone
Referring Contact Email
Participant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Gender
*
Male
Female
Non-binary
Prefer not to say
Emergency Contact
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Housing Situation and Referral Details
Current Living Situation
*
Homeless
Couchsurfing / Staying with others
Transitional Housing
Hospital / Rehab
Other
Current Living Situation - Other (specify)
Brief Summary of Situation / Reason for Housing Need
*
Health, Substance Use, and Legal History
Medical & Mental Health History
*
Mental Health Diagnosis (if any)
*
Substance Use History
*
Alcohol
Drugs
None
If yes, explain (Substance Use History)
Are you currently on parole or probation?
*
Yes
No
PO Name/Phone Number
Income, Disability, and Support Needs
Do you have a source of income?
*
Yes
No
Income Source Type
*
SSI
SSDI
VA Benefits
Employment
Other
Other Income Source (specify)
Monthly Income Amount
*
Any disabilities or accommodations needed?
*
Yes
No
If yes, explain (Disabilities or accommodations)
Preferred Room Type
*
Shared Room
Private Room (if available)
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
If no, please explain (ADLs)
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Home health / support service - Agency Name (if applicable)
Acknowledgment, Participant, and Staff Signatures
Participant Name
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Staff Name
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: