Supportive Housing Client Intake Form Date of Intake * MM DD YYYY Referral Agency / Name of Referrer First Name Last Name Full Name * First Name Last Name Date of Birth * MM DD YYYY Age * Social Security Number (Last 4 digits) * Phone Number * (###) ### #### Email Address * Gender * Male Female Non-binary Prefer not to say Emergecny Contact Number * (###) ### #### Current Living Situation * Homeless Couchsurfing / Staying with others Transitional Housing Jail / Prison Release Hospital / Rehab Other Referral Source (if applicable) Self Agency Parole / Probation Hospital or Treatment Center Family / Friend Referring Contact Name First Name Last Name Referring Phone / Email Brief Summary of Situation / Reason for Housing Need * Medical & Mental Health History (List Below) * Substance use history (if any) * Alcohol Drugs None Are you currently on parole or probation? (List PO Name/Phone Number) * Yes No Are you a registered sex offender? * Yes No Do you have a source of income? * Yes No SSI SSDI Employement Other Monthly Income Amount (if any) In USD Any disabilities or accommodations needed? Yes No Preferred Room Type * 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 Do you currently have or need a home health care provider or outside support service? * Yes, Agency Name (if applicable) No 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. * I understand I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins. * I aggree I acknowledge that violating rules may result in a strike or dismissal from the program. * I aggree 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 * First Name Last Name Date * MM DD YYYY Staff Name First Name Last Name Date * MM DD YYYY Thank you!
