The Cynoya - SHORT INTAKE / ELIGIBILITY SCREENING
STAFF Form - Please fill out this form completely to help determine eligibility
Client Information
Clients Name
*
First Name
Last Name
Date of Birth
*
Expected Release Date
*
Facility/Program
*
Referring Staff Information
Referring Staff Name
*
First Name
Last Name
Referring Staff Title/Role
Please Select
Parole Officer
Case Worker
Prison Guard
Other
Referral Staff Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Staff Email
example@example.com
Eligibility Check (check all that apply)
*
Male, age 45 or older
Able to live independently (no medical or daily care required)
No history of arson, sex offenses, or severe violence
Willing to follow structured house rules and staff direction
No active psychosis or unmanaged mental health condition
Not currently requiring detox or inpatient treatment
Comfortable with security cameras in common areas
Willing to participate in a non-clinical, structured living environment
Income Benefits Status (check all that apply)
*
SSI / SSDI
VA Benefits
Pension / retirement income
Employment income
No income (require agency sponsorship)
Other
If Other Income, please specify
Total Benefits Income
*
Documentation Status (check only if currently available)
*
State ID or Driver’s License
Social Security Card
Birth Certificate
Medical card / benefits verification
Documentation pending (can be supported by parole/case management)
Signature
Submit
Submit
Should be Empty: