Participant Intake & Enrollment Application

Date of Intake

Referral Agency/ Name of Referrer (if applicable):

Participant Information

Full Name:

Date of Birth:

Age:

Social Security Number (Last 4 digits):

Phone Number:

Email Address:

Gender:

Male

Female

Non-binary

Prefer not to say

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

Current Living Situation

Other:

Referral Source (If Applicable)

Multi choice

Self

Agency:

Multi choice

Parole/Probation Self

Hospital or Treatment Center

Family/Friend

Parole/Probation

Referring Contact Name (if applicable):

Phone/Email:

Brief Summary of Situation / Reason for Housing Need

Medical & Mental Health History (List Below)

Long answer

Mental health diagnosis (if any):

If yes, explain:

Legal Background

Are you currently on parole or probation? (List Parole Officer Name/Phone Number - If Applicable):___________________________________________________________________

Yes

Are you a registered sex offender?

Yes

Income Information

Monthly Income Amount (if any): $

Housing Preferences or Needs

Any disabilities or accommodations needed?

Yes

If yes, explain:

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 other 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 (ADL) without assistance?

Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?

Yes

No – Please explain:

Do you currently have or need a home health care provider or outside support service?

Yes – Agency Name (if applicable):

Do you currently have or need a home health care provider or outside support service?

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 Initials:

Date

Program Agreement Preview

I 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 Declaration

I acknowledge that violating rules may result in a strike or dismissal from the program.

Application Declaration

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:

Participant Signature:

Date:

Staff Name:

Signature:

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Participant Intake & Enrollment Application

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