Participant Intake Application

Participant Intake Application

PLEASE COMPLETE THIS FORM IN ITS ENTIRETY. Someone will review your application and contact you regarding your eligibility or next steps as soon as possible. Please allow 2-5 business days for a response.
Applicant Information
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address / Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Emergency Contact Information
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Applicant
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Referral Information
How were you referred to North Star Community Housing?

Other
Other referral description
Referring Agency / Contact Name
Referring Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referring Contact Email
example@example.com
Background and Housing Situation
Background - current situation

Other
Other background description
Describe your current housing situation and what led you to apply
Do you have any income at this time? If so, please describe
Health and Medical Disclosure
Do you have a disability, chronic illness, or other health condition you would like to disclose?
If yes, describe the condition and any accommodations needed
Are you currently taking any prescription medications?
If yes, list current medications, dosage, and prescribing doctor
Do you have any known allergies staff should be aware of in an emergency?
Substance Use, Mental Health, and Legal History
Are you currently or have you ever abused any substances, drugs, or alcohol?
Substance use details
Have you ever been diagnosed with a mental health disorder?
Mental health diagnosis details
Are you currently on probation or parole?
Probation or parole details
Have you been convicted of a felony?
Felony conviction details
Eligibility, Goals, and Documentation
Eligibility Confirmation
Goals - What are you hoping to achieve during your time in this program?
How did you hear about us
Required Documentation
Applicant Signature
Upload Documents

Cancelof
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Participant Intake Application

Applicant Information

Emergency Contact Information

Referral Information

Background and Housing Situation

Health and Medical Disclosure

Substance Use, Mental Health, and Legal History

Eligibility, Goals, and Documentation