Gentle Hands Supported Living for Veterans Intake Form
Personal Information
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
ID Provided:
*
State ID
Driver's License
Other
ID Number:
*
Expiration Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security Number:
*
Current Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Gender
*
Male
Female
Transgender
Other Specify
Race
*
White
Black or African American
Hispanic or Latino
Asian
Native American
Other
What is your primary language:
*
What is your relationship status?
*
Single
Married
Married but separated
Divorced
Other Specify
This form is being completed by:
*
Myself (participant)
Community referral
Case manager/ Social worker
Other
Case manager Name, Organization, Email, Telephone number:
*
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Housing & Referral Information
Preferred Move-In Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred room type
*
Private
Single
Do you require assistance with:
*
Transportation
Medication self-management support
Daily routines
None
Are you comfortable sharing common spaces with other adults?
*
Yes
No
Current living situation:
*
Homeless/unsheltered
Staying with others
Transitional housing
Jail/prison
Hospital/rehab
Rental/own home
Other
Referral Source:
*
Self
Agency
Parole/probation
Hospital/treatment center
Family/friend
Other
Is the applicant at risk of homelessness?
*
Yes
No
If yes, describe current circumstances:
*
Length of current homelessness episode:
*
Not homeless
Less than 1 month
1-6 months
6-12 months
1-2 years
2-3 years
3+ years
Shelter stays in the past four years, if applicable (names/dates):
*
Where has the applicant stayed during the past 30 days? Check all that apply:
*
Street, park, vehicle, or other place not meant for habitation
Transitional housing
Staying with friends or family
Rental housing
Own apartment or house
Motel or hotel
Hospital or rehabilitation facility
Psychiatric facility
Substance-use treatment facility
Jail or prison
Domestic violence shelter
Foster care
Other
Has the applicant previously lived in shared housing or a group-home setting?
*
Yes
No
If yes, briefly describe what worked well and any challenges experienced:
*
Is the applicant currently receiving housing subsidy or rental assistance?
*
Yes
No
Gentle Hands Supported Living | Confidential Applicant Information
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If yes, type of subsidy or assistance:
*
Did the applicant pay their own rent in their last housing arrangement?
*
Yes
No
Did the applicant pay their own utilities in their last housing arrangement?
*
Yes
No
Reason for leaving the last housing arrangement: Check all that apply.
*
Unpaid rent
Other eviction
Conflict with family or friends
Overcrowding
Domestic violence
Incarceration
Hospitalization or treatment
Housing condemned
Fire
Other
If immediate housing is not available, may Gentle Hands refer the applicant to other housing/community resources?
*
Yes
No
Legal Information
Does applicant have a conservator? If yes, please list
*
Yes
Conservator list
Does applicant have any current legal issues? If yes, please list description of charges and any pending court dates.
*
Yes
Legal issues description
Does applicant have any prior arrests, convictions or incarceration? If yes, please list.
*
Yes
Prior arrests list
Is applicant currently on parole?
*
Yes
No
Conviction(s):
*
Does applicant have legal representation? If yes, please list name and address and phone number of attorney or legal advocate.
*
Yes
If yes, please list name and address and phone number of attorney or legal advocate.
Is the applicant register as sex an offender? If yes, describe what happened.
*
Yes
Description of what happened
Health & Medical Info
Does the applicant have any current or past medical conditions that Gentle Hands should be aware of? If yes, explain:
*
Yes
Medical conditions explanation
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Are you currently taking any medications?
*
Yes
No
If yes, list:
*
Medications
*
Rows
Medication name
Dose
Schedule / frequency
Prescriber
Self-managed?
1
2
3
4
5
6
Pharmacy Name and Phone:
*
Date of last physical, OB/GYN appointment (if applicable), and dental appointment:
*
Primary Care Provider Name:
*
First Name
Last Name
Phone:
*
Format: (000) 000-0000.
Please list hospitalizations for these medical conditions.
*
Does the applicant receive home health, personal care, or other supportive services?
*
Yes
No
If yes, provider name, contact, and services:
*
Do you need home health, personal care, or other supportive services?
*
Yes
No
Areas where the applicant may benefit from outside support or referral:
*
Rent/utilities
Lease compliance
Housekeeping
Budgeting
Transportation
Apartment repairs
Mental-health services
Health services
Benefits
Meal preparation
Shopping
Prescription filling
Socialization
Hygiene
Other
Support & Behavioral Info
Is the applicant a veteran who has served on active duty?
*
Yes
No
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Child Welfare Involvement: For Parents of minor children, including non-custodial parents, history of child welfare involvement, including current case status:
*
What type of housing subsidy is the applicant receiving?
*
Does applicant have a disability of a long duration?
*
Yes
No
I don't know
Do you have a history of any of the following:
Substance use if yes, what/ frequency/ last date of use?
Other
Mental health treatment / Behavioral issues in shared housing / Mental illness if yes, what
*
Mental health treatment
Behavioral issues in shared housing
Other
Alcohol abuse if yes, what/ frequency/ last date of use?
*
Yes
Other
Drug overdose if yes, when and what?
*
Other
Disabilities
*
HIV/AIDS and related diseases
Developmental disability
Physical disability
None
Check all that apply.
*
Homicidal ideas/attempts
Assaultive behavior
Delusions
Severe depression
Severe thought disorder
Cognitive impairment
Suicidal ideas
Suicidal attempts
Hallucinations
Arson/fire setting
Victim of Sexual abuse/assault
Victim of Trauma
Other
Does applicant have any current or past history of substance abuse treatment? If yes, where/when?
*
No
If yes, where/when?
Is applicant involved in any 12-step or other self-help recovery programs? If yes, where/when?
*
No
If yes, where/when?
Does applicant have a history of any psychiatric conditions?
*
Yes
No
If yes, please list hospitalizations for these conditions.
*
Does applicant receive psychiatric care? If yes, please list name, address and phone number of all psychiatric care providers.
*
No
If yes, please list name, address and phone number of all psychiatric care providers.
Gentle Hands Supported Living | Confidential Applicant Information
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Do you have a caseworker or social service contact?
*
Yes
No
Name:
*
First Name
Last Name
Phone:
*
Format: (000) 000-0000.
If no, would you like one?
*
Yes
No
Is applicant allergic to any medications If yes, what and reaction?
*
Does the applicant participate in any social networks or recreational activities? If yes, please identify the training program:
Is applicant currently participating in vocational or employment training programs?
*
Yes
No
If yes, please identify the training program?
Does the applicant have difficulty with any of the following areas of daily living? In addition, please list any strengths the tenant may have. Check all that apply.
*
Paying Rent/ Utilities
Lease Compliance
Housekeeping
Money Arrangement
Driving / Using public transportation
Arranging apartment repairs
Use of mental health services
Use of health services
Securing / Maintaining Benefits
Meal Preparation
Shopping for food and other necessities
Filling Prescription
Socialization
Hygiene
Other
Do you anticipate bringing an animal with you if accepted into the program?
*
Yes
No
If yes, please indicate:
Note: Gentle Hands Supported Living complies with all applicable federal, state, and local fair housing laws regarding service animals and emotional support animals. Additional documentation may be requested for emotional support animals when permitted by law.
Financial Information
Financial Information Sources
*
a. Social Security Income (SSI)
b. Social Security Disability Income (SSDI)
c. General Assistance (SAGA)
d. Temporary Aid to Needy Families (TANF)
e. Child Support
f. Alimony
g. Veteran Benefits
h. Employment Income
i. Unemployment
j. Medicare
k. Medicaid
l. Food Stamps
m. No financial resources
Other
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Monthly Income Estimate: $
*
Are any benefits/entitlements pending?
*
Yes
No
If yes, type, application date, and expected amount:
Outstanding debts or financial obligations relevant to housing:
*
Employment status:
*
Part-time
Full-time
Self-employed
Not employed
Please list any financial obligations including the amount (e.g. child support, alimony)?
Able to pay community fee and rent on time?
*
Yes
No
Needs to discuss
Would the applicant like help applying for rental assistance if available?
*
Yes
No
Housing Preferences & Needs
Do you have any allergies (food/environmental)?
*
Yes
No
List
If immediate housing is not available through Gentle Hands Supported Living, do you give us permission to refer you to other similar housing programs or community resources that may be able to assist you?
*
Yes
No
Does the applicant need a reasonable accommodation or accessibility-related modification because of a disability?
*
Yes
No
If yes, describe the accommodation or modification requested:
Gentle Hands Supported Living is an independent living program and does not provide assistance with activities of daily living (ADLs). Can you independently perform your activities of daily living (ADLs), including bathing, dressing, toileting, transferring, eating, and personal hygiene?
*
Yes
No
Agreement & Signature
I certify that the information provided is true and complete to the best of my knowledge. I understand that submission of this form does not guarantee acceptance or placement. Applications are reviewed based on eligibility, program fit, verification requirements, and availability.
I understand that Gentle Hands Supported Living is an independent-living housing program and does not provide medical care, personal care, supervision, medication administration, transportation, or assistance with
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activities of daily living. I am responsible for managing my personal care, medical needs, medications, transportation, and daily living tasks.
I understand that Gentle Hands Supported Living is a drug- and alcohol-free program. I agree to comply with program rules and understand that failure to comply may result in corrective action or discharge, consistent with program policy and applicable law.
I understand and agree to the statements above:
*
Yes
No
Applicant Print Name:
*
First Name
Last Name
Applicant Signature:
*
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Co-Signer Print Name:
First Name
Last Name
Co-Signer:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gentle Hands Supported Living | Confidential Applicant Information
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