Housing Intake Form

Housing Intake Form
Move In Date

MonthDayYear
Member Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Last 4 of Social Security Number
E-mail
example@example.com
Gender:
Current Living Situation

Other
Referral Source
Reffering Source's Name:

First NameLast Name
Referring Source's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referring Source's Email:
example@example.com
Brief Summary of Situation/ Reason for Housing Need:
Medical/ Behavioral Health History
Substance Use History
Do you smoke cigarettes, cigars, marijuana?
Legal Background
Are you currently on parole or probration?
If you are on parole or probation, what is the Name/Phone Number of the Parole or Probation officer:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Income Information
Do you have a source of income?
What form of income do you receive?

Other
Monthly Income
Housing Preferences or Needs:
Any disabilities or accomadations needed?
Preferred Room Type:
Can you live indepnedently?
If no, please explain
Can you manage your Activities of Daily Living (ADLs) without assistance?
If no, please explain:
Do you currently have or need a home health care provider or outside support service?
If yes, Agency Name/Phone Number:
Current Rental Information
Present Landlord/ Housing Program (If Applicapable)

First NameLast Name
Name of Housing Program (If Applicapable)
Present Landlord’s / Housing Program's Phone
Format: (000) 000-0000.
Next of Kin/ Emergency Contact
Full Name

First NameLast Name
Relationship to you:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Independent Living & Functionality Acknowledgment
Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance,or supervision.
You must be able to manage your own:
* Personal hygiene and grooming
* Meal preparation and eating
* Medication managment (unless managed by an outside provider)
* Mobility and transportation arrangements
* Housekeeping and laundry
* Daily living responsibilities
If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.
Member's Initials
I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.
Member's Initials:
I acknowledge that violating rules may result in a strike or dismissal from the program.
Member's Initials
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.
Member's Initials:
Applicant Declaration
I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.
Full Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Document
Proof of Income

Cancelof
The Applicant consents to the collection, use and disclosure of the Applicant’s personal information by the Landlord and/or agent of the Landlord, from time to time, for the purpose of determining the creditworthiness of the Applicant for the leasing, selling or financing of the premises or the real property, or making suchother use of the personal information as the Landlord and/or agent of the Landlord deems appropriate.

By submitting this form, The Applicant represents that all statements made above are true and correct. The Applicant is hereby notified that a consumer report containing credit and/or personal information may be referred to in connection with this rental. The Applicant authorizes the verification of the information contained in this application and information obtained from personal references. This application is not a Rental or Lease Agreement. In the event that this application is not accepted, any deposit submitted by the Applicant shall be returned.
Should be Empty:

Housing Intake Form

Member Information

Legal Background

Income Information

Housing Preferences or Needs:

Current Rental Information

Next of Kin/ Emergency Contact

Independent Living & Functionality Acknowledgment

Applicant Declaration

Additional Document