Intake Form

Please complete the following intake form to help us assess your eligibility for our housing program. All information provided is confidential.

If you’d rather fill out a hard copy, you can download it in the box to the right.

Basic Information Name: Phone: Email:

Gender:
Male Female Prefer not to answer

Best way to contact you?
Phone Email Text

Income & Financial Stability

Do you have guaranteed income or financial assistance?
Yes No

Income Source(s):
Employment SSI SSDI VA Benefits Other

Monthly Income:

Housing Readiness

Can you live in a shared environment?
Yes No

Perform daily living tasks independently?
Yes No

Have you ever been evicted or asked to leave a program?
Yes No

How soon are you looking to move? Primary goals for living in this program:

Do you have a support system?
Yes No

If yes, describe:

Do you have a Payee?
Yes No

Require assistance with any ADLs?
Yes No

If yes, select:
Bathing Dressing Ambulating

Mental & Physical Health

Mental health challenges?
Yes No

If yes, please specify:

Currently receiving mental health treatment?
Yes No

If yes, provider & frequency:

Medication for mental health?
Yes No

Benefit from wellness resources?
Yes No

History of substance use or recovery?
Yes No

Medical Needs & Accessibility

Take prescribed medication?
Yes No

Specific medical conditions impacting housing?
Yes No

Require mobility aids?
Yes No

Food allergies or dietary restrictions?
Yes No

Require medication storage support?
Yes No

Relocation & Additional Assistance How soon are you looking to move? Do you require assistance with any of the following?
Applying for SNAP benefits
Job Placement
Applying for VA benefits
Clothing Donations
Health Insurance Enrollment
Medication Pickup
Medication Reminders
Applying for SSI/SSDI

Personal Goals & Lifestyle Main goals for living in this program: How long do you anticipate staying with us?

Do you participate in any support programs or case management?
Yes No

Final Agreement

I understand that this program has rules & guidelines and is designed for individuals who can live independently in a shared environment. I understand this is an Independent Housing Program.

Applicant Signature: Date:

Intake Form

Downloadable Form