REFERRAL INTAKE PACKET
Referral Date
*
-
Month
-
Day
Year
Date
Referral Agency/Organization
*
Referring Person Name
*
Title/Position
*
Phone Number
*
Email Address
*
Relationship to Applicant
Self-Referral
Family Member
Friend
Shelter/Program Staff
Case Manager
Social Worker
Community Agency
Other
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Applicant Information
Full Legal Name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Email Address
Current Address City/State/Zip
Emergency Contact Name/Phone Number/Relationship
Current Living Situation
*
Couch Surfing
Homeless
Shelter
Hotel/Motel
Living with Family/Friends
Apartment/Home
Transitional Housing
Other
Length of Current Living Situation
Reason for Seeking Housing
*
Have you ever been evicted?
*
Yes
No
If yes, explain
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INCOME & EMPLOYMENT VERIFICATION
Primary Source of Income
*
Employment Income
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
Retirement/Pension
Veterans Benefits
Unemployment Benefits
Child Support
Self-Employment
Family Support
Other
Employer/Income Source Name
*
Monthly Gross Income Amount
*
Pay Frequency
*
Weekly
Biweekly
Monthly
Other
Do you receive fixed income benefits?
*
Yes
No
If yes, type
SSI
SSDI
Retirement
Veterans Benefits
Other
REQUIRED VERIFICATION DOCUMENTS Please provide copies of the following: ☐ Government-Issued Photo ID ☐ Proof of Income/Benefits ☐ SSI/SSDI Award Letter ☐ Recent Pay Stubs ☐ Bank Statement (if requested) ☐ Emergency Contact Information ☐ Other Supporting Documents
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EMPLOYMENT INFORMATION
Current Employer
Job Title/Position
Supervisor Name
Supervisor Phone Number
Length of Employment
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HEALTH & INDEPENDENT LIVING SCREENING
Helping Hands Independent Living Home LLC is NOT a licensed assisted living, medical, or healthcare facility. Residents must independently manage: Medications Transportation Personal hygiene Meals Daily living activities Do you require assistance with daily living activities?
*
Yes
No
If yes, explain:
Do you independently manage your medications?
*
Yes
No
N/A
Applicant Initials
*
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BACKGROUND INFORMATION
Have you ever been convicted of a violent felony?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
If yes, explain
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COMMUNITY EXPECTATIONS
Residents are expected to: Pay occupancy fees on time Follow house rules Respect quiet hours and visitor policies Maintain cleanliness Respect fellow residents and staff Maintain independent living responsibilities Do you agree to these terms?
*
Yes
No
Applicant Initials
*
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APPLICANT CERTIFICATION
I certify that the information provided in this intake packet is true and complete to the best of my knowledge. I understand that false information may result in denial of housing or termination of occupancy.
*
Yes
No
Applicant Initials
*
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