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Intake Form
Intake form
Step
1
of
4
25%
Basic Information
Name
Date of Birth
MM slash DD slash YYYY
Phone Number
Email Address
Current Address
Emergency Contact Name
Emergency Contact Phone Number
Preferred Method of Contact
Phone
Email
Text
Placement Information
Are you seeking housing for yourself or someone else?
Myself
Someone Else
Current living situation
Homeless
Staying with friends/family
Hospital
Other
Reason for seeking placement/services
Desired move-in date
MM slash DD slash YYYY
Are you currently receiving SSI, SSDI, or other benefits?
Yes
No
Pending
Monthly income amount (if applicable)
Do you have a case manager or social worker?
Yes
NO
Medical & Support Needs
Do you require medication reminders or assistance?
Yes
NO
Do you have any mobility limitations?
Yes
NO
Do you require transportation assistance?
Yes
NO
Are there any dietary restrictions or allergies?
Yes
No
Describe your Allergy
Are you currently receiving mental health services?
Yes
NO
Do you require supervision or daily living support?
Yes
NO
Additional Information
Preferred room type
Private
Shared
Have you lived in an ILF/group home before?
Yes
No
Any legal restrictions or special considerations?
Additional comments or concerns
