Resident Intake Application

Resident Intake Application

Complete the resident intake application with your contact, history, health, assistance, benefit, employment, payment, and lifestyle details. Use all fields from the source PDF.
Applicant Information
Full Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Pronouns
Physically Independent
Primary Contact
Primary Contact Name

First NameMiddle NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Contact
Secondary contact name

First NameMiddle NameLast Name
Relationship to applicant
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Behavioral/Legal History
History of suicide attempts, gestures, or ideation?
If yes, please explain
History of violent or assaultive behavior?
If yes, please explain
History of malicious behavior such as fire setting or retaliation?
If yes, please explain
Registered sex offender?
If yes, please explain
Felony convictions?
If yes, please explain
Substance Use History
History of alcohol or drug use?
If yes, please specify
Date of last use

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Longest period of abstinence
Types of substance abuse treatment received in the past, with dates
Health & Medications
Health conditions

Other
Other health condition (specify)
Explain medical conditions and list any not shown above
Current medications (prescription and over-the-counter)
Income/Assistance
Types of assistance currently receiving
SSI amount per month
SSDI amount per month
Welfare details
Food stamps details
Insurance/Benefits
Medicaid Coverage
Medicaid ID Number
Medicare Coverage
Medicare ID Number
Veterans Affairs Coverage
VA ID Number
Tricare Coverage
Tricare ID Number
Employment & Payment
Employment plans (if applicable)
How will you pay for accommodations while staying at Hudson's Safe Haven House?
Lifestyle/Preferences
Smoker?
Personal organization style
Social style
Ever been faced with eviction?
If yes, please explain
Should be Empty:

Resident Intake Application

Applicant Information

Primary Contact

Secondary Contact

Behavioral/Legal History

Substance Use History

Health & Medications

Income/Assistance

Insurance/Benefits

Employment & Payment

Lifestyle/Preferences