Supportive Housing Client Intake Form Date of Intake *Participant InformationFull NameDate of BirthAgeSocial Security Number (Last 4 digits)Phone NumberEmail AddressGenderMaleFemaleNon-binaryPrefer not to sayEmergency Contact NameRelationshipEmergency Contact PhoneCurrent Living SituationHomelessCouchsurfing / Staying with othersTransitional HousingJail/Prison ReleaseHospital / RehabOtherReferral Source (If Applicable)SelfAgencyParole/ProbationHospital or Treatment CenterFamily/FriendReferring Contact NamePhone/EmailBrief Summary of Situation / Reason for Housing NeedMedical & Mental Health History (List Below)Mental health diagnosis (if any)Substance use history (if any)AlcoholDrugsNoneIf yes, explainLegal BackgroundAre you currently on parole or probation? (List PO Name/Phone Number)YesNoAre you a registered sex offender?YesNoIncome InformationDo you have a source of income?YesNoSSISSDIEmploymentOtherMonthly Income Amount (if any)Housing Preferences or NeedsAny disabilities or accommodations needed?YesNoIf yes, explainPreferred Room TypeShared RoomPrivate Room (if available)Independent Living & Functionality AcknowledgmentOur 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 groomingMeal preparation and eatingMedication (unless managed by an outside provider)Mobility and transportation arrangementsHousekeeping and laundryDaily living responsibilitiesCan you live independently and manage your Activities of Daily Living (ADLs) without assistance?YesNoIf No – Please explainDo you currently have or need a home health care provider or outside support service?YesNoIf Yes – 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 InitialsDateProgram Agreement PreviewI 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 DeclarationI 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 NameParticipant SignatureDateStaff NameSignatureStart signing your signature hereYour browser does not support e-Signature field.DateSubmit
