Miles Forward Living Supportive Housing Intake Form

Housing Intake Form

Please fill out this form to help us understand your needs and provide appropriate housing support.
Clients Full Name*

First NameLast Name
Clients Phone Number*
Please enter a valid phone number.
Do we have permission to text/leave voicemail on the phone number provided?*

YesNo
Email
example@example.com
Gender*

MaleFemaleTransgender
Date of Birth*

MonthDayYear
Date
What is your current living situation?*

Living with a friendLiving in a carShelterHomelessHospital/FacilityShared Living
When does client need to be placed?*

MonthDayYear
Date
What type of room preferred?*

SharedPrivate
Are you able to live independently?*

YesNo
How will you be able to pay? (Proof of income is required)*

SSI/SSDIRetirementJobNo IncomeOther/Unsure
How much income do you receive monthly? If none please type NONE*
Do you have any disabilities or special needs?*

YesNo
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?*

YesNo
Do you have any mental health conditions?*

YesNo
If yes, please provide details?*
Is the client an ex-offender?*

YesNo
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*

YesNoWith 1000ft restrictionWithout 1000ft restriction
Are you currently on probation or parole?*

YesNo
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

YesNo
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How do you hear about us?*

ReferralSocial WorkerSearch Engine/WebSocial MediaOther
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
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