Housing Intake Form
Please fill out this form to help us understand your needs and provide appropriate housing support.
Clients Full Name
*
First Name
Last Name
Clients Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave voicemail on the phone number provided?
*
Yes
No
Email
example@example.com
Gender
*
Male
Female
Transgender
Date of Birth
*
-
Month
-
Day
Year
Date
What is your current living situation?
*
Living with a friend
Living in a car
Shelter
Homeless
Hospital/Facility
Shared Living
When does client need to be placed?
*
-
Month
-
Day
Year
Date
What type of room preferred?
*
Shared
Private
Are you able to live independently?
*
Yes
No
How will you be able to pay? (Proof of income is required)
*
SSI/SSDI
Retirement
Job
No Income
Other/Unsure
How much income do you receive monthly? If none please type NONE
*
Do you have any disabilities or special needs?
*
Yes
No
If yes, please describe your disabilities (if none, place N/A)
*
Does the client require a Handicap Accessible living environment?
*
Do you have any history of substance abuse?
*
Yes
No
Do you have any mental health conditions?
*
Yes
No
If yes, please provide details?
*
Is the client an ex-offender?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you currently on probation or parole?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
*
Yes
No
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How do you hear about us?
*
Referral
Social Worker
Search Engine/Web
Social Media
Other
Any additional information you would like to provide:
Guests are not required to pay a security deposit. A one-time, non-refundable $150 fee covers administrative costs, maintenance, and cleaning for the entire duration of each stay. This is due before moving in. Do you agree?
*
Yes/No
Signature
Continue
Continue
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