Diana Harbor & Haven FoundationHousing Referral & Resident Intake Form (JotformTemplate)
Section 1- Referral Information
Who is completing this form? (Applicant, Case Manager, Social Worker, Hospital, Probation/Parole, Family, Other)
Agency Name
Referrer Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Relationship to Applicant
Section 2 - Applicant Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Gender
Phone
Format: (000) 000-0000.
Email
example@example.com
Current Address
Emergency Contact
Emergency Contact Phone
Format: (000) 000-0000.
Relationship
Section 3 - Housing Request
Move-in timeframe
Room Preference: Shared or Private
Monthly Rent Range: $650-$890 (based on room type, availability, and program placement)
Payment Source (SSI, SSDI, Employment, Representative Payee, Sponsor, County Funding, Other)
Section 4 - Current Living Situation
Current living situation
Reason housing is needed
Discharge date (if applicable)
-
Month
-
Day
Year
Date Picker Icon
Section 5 - Independence Assessment
Can independently bathe, dress, toilet, walk, prepare meals, clean room, do laundry, follow house rules, manage medications.
Needs medication reminders?
• Transportation assistance needed?
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Section 6 – Medical Information
• Diagnoses
• Current Medications
• Allergies
• Mobility (Cane/Walker/Wheelchair/Oxygen/CPAP)
• Falls in last year
• Dietary restrictions
Section 7 – Behavioral & Safety Screening
• History of violence/aggression/arson
• Pending charges
• Probation/Parole
• Substance use history
• Recovery status
• Background check authorization
Section 8 – Mental Health
• Diagnosis (if known)
• Therapist
• Psychiatrist
• Receiving treatment?
Section 9 – Employment & Income
• Employment status
• Employer
• Hours/week
• Monthly income
• Representative Payee information
Section 10 – House Compatibility
• Comfortable sharing living space
• Quiet environment
• Smoking
• Visitors
• Pets
• Comfortable living with seniors, returning citizens, adults with disabilities, individuals in recovery
Section 11 – Support Services Needed
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Employment
GED
Transportation
Mental Health
Food Assistance
Benefits
Budgeting
Life Skills
ID Replacement
Housing Navigation
Section 12 – Program Agreement
Applicant acknowledges: Safe Sober Living home; Not a medical facility; Medication reminders only;
Monthly rent ranges from $650–$890 depending on room type and placement;
$200 non-refundable administration fee;
30-day written notice before moving out;
House rules; Drug- and alcohol-free environment; Ring cameras in common areas; Background check authorization.
Section 13 - Required Uploads
Photo ID
Social Security Card
Insurance Card
Income Verification
Award Letter
Medication List
Section 14 – Staff Use Only
Assessment outcome
Assigned house
Assigned room
Approved Monthly Rent ($650–$890)
Move-in date
House manager
Notes
Section 15 – Signature
Applicant Signature
Date
-
Month
-
Day
Year
Date Picker Icon
• Staff Signature
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