Eligibility & Intake Form

Eligibility & Intake Form

Provide your details and history so we can confirm eligibility and plan your move-in.
Getting to know you
First and last name

First NameLast Name
If you're interested in moving forward, may I begin the assessment to confirm eligibility?
Funding & move-in
Do you have a case manager who recommended you?
Case manager name

First NameMiddle NameLast Name
Case manager phone number
Please enter a valid phone number.Format: (000) 000-0000.
Case manager email
example@example.com
Case manager organization
Main income source
Monthly income amount
Are you receiving funding assistance for move-in costs from an organization?
Desired move-in date

MonthDayYear
Date
Can you pay first month's rent on the day of move-in? Note: if move-in is after the 3rd, the second month is prorated.
Personal information
Best Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Last 4 Digits of National ID
Height
Weight
Have you lived in a room and board or residential program before?
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship and Notes
Most Recent Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Most Recent Home Contact Name
Most Recent Home Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Leaving
Do you have a driver's license or ID?
Do you receive government assistance?

Other
Government Assistance Details
Health & wellness
Physical health conditions
Special needs or assistance needed for daily living
Mental health diagnoses
Medication adherence history
Current medications and medication reminder needs
Known allergies
Current medical insurance
Have you ever had thoughts of self-harm or suicide, or attempted suicide?
Background
Ever been arrested, charged, or convicted of a crime or felony?
If yes, provide details for each incident
Have you ever used marijuana, methamphetamine, opioids, opiates, heroin, fentanyl, or any controlled or street drugs?
If yes, please explain and provide last use
Alcohol use

Other
Tobacco use

Other
Should be Empty:

Eligibility & Intake Form

Getting to know you

Funding & move-in

Personal information

Health & wellness

Background