Small Steps Home Care Intake Form

Shared Housing Interest Form

Submit your preferences and contact details to find your ideal shared living arrangement.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client is 18 years old or older
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Location(s)
Monthly Budget Range (USD)
Preferred Housemate Characteristics

Other
Additional Comments or Requirements
Emergency Contact Name:
Relationship:
Emergency Contact Phone Number
Client reports no available emergency contact information
Current Living Situation:

Other
HOUSING HISTORY - How long has the client been without stable housing?
PRIMARY REASON HOUSING IS NEEDED NOW

Other
Additional Comments or Requirements
DISCHARGE INFORMATION - If being discharged, is there a discharge date or deadline we should know about?
How soon does the client need housing?
Minimum Stay Requirement: This program has a minimum stay requirement of 3 months. Residents may remain as long as they follow house guidelines and meet program expectations.
INCOME INFORMATION - Is the client able to contribute toward monthly housing costs?
Approximate Monthly Income: $
Source of Income:
Other Source of income put here:
If Client Has No Current Income
If no income, is there a pending benefit or income source?
LEVEL OF INDEPENDENCE

(This is a non-medical independent living home)
Bathe & Dress
Manage their own medications?
Prepare simple meals?
Follow house rules & structure?
MOBILITY STATUS
Transportation Access:
Does the client have reliable transportation for appointments, work, or supervision requirements?
BEHAVIORAL & SAFETY SCREENING
History of violence?
If yes, explain:
Active substance use?
Mental health condition the case manager believes may impact shared living (if known):
Any behaviors that could impact shared living?
MEDICATION RESPONSIBILITY
Is the client able to self-administer medications without supervision?
Sex Offender Status: Is the client required to register as a sex offender?
Shared Living History: Has the client previously lived in shared or group housing?
Shared Living Comfort: Is the client comfortable sharing a bedroom and common living spaces with other residents?
CONTACT SECTION
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ACKNOWLEDGMENTI understand this is a non-medical independent living facility and does not provide nursing care, medication administration, or personal care services.
Should be Empty:

Shared Housing Interest Form

LEVEL OF INDEPENDENCE

BEHAVIORAL & SAFETY SCREENING

MEDICATION RESPONSIBILITY

CONTACT SECTION