Intake Form

Date of Intake:

Referral Agency/ Name of Referrer:

Participant Information

Full Name:

Date of Birth:

Age:

Social Security Number (Last 4 digits):

Phone Number:

Email Address:

Multiple Choice

Male
Female
Non-binary
Prefer not to say

Emergency Contact Phone:

Emergency Contact Name:

Relationship:

Current Living Situation

Agency:

Typе: or of

Referring Contact Name:

Phone/Email:

Brief Summary of Situation / Reason for Housing Need

Medical & Mental Health History

Mental health diagnosis (if any):

Substance use history (if any):

Alcohol
Drugs
None

If yes, explain:

Legal Background

Are you currently on parole or probation? (List PO Name/Phone Number)

Yes
No

Are you a registered sex offender?

Yes
No

Income Information

Do you have a source of income?

Other:

Monthly Income Amount (if any): $

Housing Preferences or Needs

Any disabilities or accommodations needed?

Yes
No

If yes, explain:

Preferred Room Typе:

Shared Room
Private Room (if available)

Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.

You must be able to manage your own:

Personal hygiene and grooming
Meal preparation and eating
Medication (unless managed by an outside provider)
Mobility and transportation arrangements
Housekeeping and laundry
Daily living responsibilities

If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?

Yes
No

Please explain:

Do you currently have or need a home health care provider or outside support service?

Yes
No

Agency Name (if applicable):

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.

Participant Initials:

Date:

Program Agreement Preview

I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.
I acknowledge that violating rules may result in a strike or dismissal from the program.

Applicant Declaration

I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.

Participant Name:

Participant Signature:

Clear Signature

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Date:

Staff Name:

Signature

Clear Signature

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Date:

Participant Information

Mental health diagnosis (if any):

Legal Background

Income Information

Housing Preferences or Needs

Independent Living & Functionality Acknowledgment

Applicant Declaration

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