Intake Form for VA and Homeless

The Cynoya - Intake Complete Form - VA & Homeless

Please fill out this form completely for placement of client
Staff / Sponsor Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
- Applicant's Legal Name*
  
  First NameLast Name
- Preferred/Nick Name
- Gender*
  
  FemaleMaleOther
- Date of Birth*
- SSN
- Most Recent Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.
- Email
  example@example.com
- Reason for Leaving Residence?
- Current Living Situation
  
  ShelterHotelCarHomelessWith Friends, RelativesOther
- Do you understand the following? (Check all that apply)
  
  Understands house rulesAgrees to background screening
- Previous Addresses (Last 2 years)
- Preferred Housing Location*
  
  Baltimore CityBaltimore CountyWashington, DCOther
- Room Type Request*
  
  Shared Room ($750)Private Room ($950 - $1100)
- Move-in Date Requested*
  
  MonthDayYear
  Date
- Sources of Income (check all that apply)
  
  SSISSDIRetirement (Pension)VA BenefitsEmploymentOther
- Currently Employed?
  
  NoYes
- Total Monthly Income Amount*
- If you are Currently Employed, fill out the Employment Information Section Below!
- Employer Name
- Employer Contact Info
- Income per Month
- Do you have proof of income?
  
  YesNo
- Primary Emergency Contact Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.
- Relationship*
- Secondary Contact Name*
  
  First NameLast Name
- Phone Number*
  Please enter a valid phone number.
- Relationship*
- Case Manager (if already assigned):
  
  First NameLast Name
- Agency Name
- Phone Number
  Please enter a valid phone number.
- Therapist (if applicable):
  
  First NameLast Name
- Probation Officer (if applicable)
  
  First NameLast Name
- Medical Conditionals (check all that apply)
  
  HypertensionAsthmaVision ImpairmentDiabetesChronic PainHearing ImpairmentHeart DiseaseMobility LimitationsOther
- If Other, please specify
- Mental Conditionals (check all that apply)
  
  DepressionPTSDDrug Abuse HistoryAnxietySchizophreniaBipolar DisorderNone ReportedOther
- If Other, please specify
- Are you currently using any illegal substances?*
  
  YesNo
- Are you willing to follow a drug‑free policy on the property?*
  
  YesNo
- List of Current Medications (if any)
- Do you need assistance managing medications?*
  
  NoYes
- TB Screening (Required)
  
  A tuberculosis (TB) screening is required to help protect the health and safety of all residents and staff living in a shared housing environment. Requiring a TB screening is a standard public health practice in congregate and transitional living settings and demonstrates a commitment to maintaining a safe, healthy living space for everyone in the home.
- Have you had a TB test within the last 12 months?*
  
  NoYes
- If no, are you willing to complete a TB test?
  
  YesNo
- I understand that my health history plays a vital role in identifying eligibility in this program. I certify that the information on this Health Screening is accurate to the best of my knowledge. I also understand that If any of this information has been falsely stated, it is grounds for immediate termination from the program.
- Do you need assistance from a caseworker in obtaining any missing documents?
  
  NoYes
- Missing Documents (check all that apply)
  
  State IDDriver’s LicenseSocial Security CardBirth CertificateMedicaid/Medicare CardVA CardBank card / prepaid cardDOC re-entry paperworkRe-entry plan from case managerProof of income letterOther
- If Other, please specify
- Copy of Identification Front
  
  Cancelof
- I understand that participation in the program may require a background check for the safety of all residents.*
  
  I consent to a criminal background check.I have provided accurate information regarding any prior convictions.
- Copy of Identification Back
  
  Cancelof
- I acknowledge that The Cynoya Independent Living Housing offers shared housing with established house rules, expectations, and program guidelines designed to ensure a safe, respectful, and clean living environment for all residents. I agree to comply with all rules and to complete the intake process truthfully and in good faith.
- Signature
Should be Empty:

The Cynoya - Intake Complete Form - VA & Homeless