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.

Personal Information

First Name: Last Name: Email Address: Phone Number: Gender:
Male Female Prefer not to answer

What best describes you?
Veteran Elderly Other

Housing & Living Arrangements

Can you live in a shared environment?
Yes No

Are you comfortable living with people of different:
Genders Race/Ethnicity Sexual Orientation

Do you have specific living space needs (allergies, mobility aids, etc)?
No Yes Preferred Rooming Arrangement: Can you live with 24/7 surveillance in shared spaces?
Yes No

Do you have guaranteed income?
Yes No

Income Source(s): Monthly Income:

Support & Independence

Do you have a support system?
Yes No Do you have a Payee?
Yes No

Can you perform your own ADLs?
Yes No Do you require assistance with any ADLs?
Yes No
Bathing Dressing Ambulating

Health & Wellness

Mental health diagnosis?
Yes No Do you take medication(s)?
Yes No

Personal Goals & Lifestyle

Main goals for living in this housing program: How long do you anticipate staying? Do you participate in support programs or case management?
Yes No

Daily Living & Compatibility

Are you okay with shared responsibilities?
Yes No

How do you handle conflict? Do you have pets?
Yes No
If yes, how many? Are you okay living with pets?
Yes No

Mental & Physical Health

Currently receiving mental health treatment?
Yes No History of substance use/recovery?
Yes No Any physical health conditions we should be aware of?

Background & Safety

Ever been evicted?
Yes No Criminal history?
Yes No

Currently on probation/parole?
Yes No

Any court orders or restrictions affecting housing?
Yes No

Relocation & Additional Assistance

How soon are you looking to move? Assistance Needed:
Applying for SNAP
Job Placement
VA Benefits
Clothing Donations
Health Insurance Enrollment
Medication Pickup
Medication Reminders
Applying for SSI/SSDI

What does a healthy, respectful environment look like to you? What support would help you succeed? Is there anything else we should know?

Program Policies & Agreements

Can you reside in a shared environment with rules?
Yes No

Can you adhere to all house rules?
Yes No