Intake Form

First name

Last name

DOB

Email

Phone

Gender

Marital Status

Referred by / Company Name

Current living situation

Are you currently employed

Yes

No

What is your current source of income?

Please explain how much? How is it issued? When do you receive?

What do you dislike and like about your current living situation?

What would you like for the program to help you with in the next 6 months to make your life better?

Do you have a support system?

ie: Family, Friends, donators, people who help your situation in a positive manner

Please list any emergency contacts

By renting or leasing this independent housing property, the tenant agrees to abide by the terms and conditions set forth herein.

Address

City/ state / postal code

Best time to reach

Time

HoursMinutes

Social security

Please identify your race in ethnicity

Do you identify as a member of the LGBTQ + community?

Yes

No

Please list the names and ages of anyone else who will be living with you?

Have you ever been convicted of a crime ? Please note answering this question does not disqualify you

Yes

No

Do you have any criminal convictions pending please no answer. This question does not disqualify you.

City and state convicted?

If you answer the above questions, please explain?

Are you transitioning from any of the following institutions?

Do you currently have a case manager, social worker orpeogram contact?

Yes

No

Are you looking for additional assistance finding these people?

Yes

No

If yes please provide name and contact information.

Do you currently or have you ever used illegal substance? Please explain

Do you have a mental illness? If yes diagnoses and has it been diagnosed by a physician?

Are you currently perscribed and medication by a licensed physican?

Yes

No

Do you self administer? Please note, we are not a medical facility and we cannot administrator medication.

Yes

No

Do you havd physical limitation or mobility needs? If so please explain?

Which Tier of housing would you be applying for ?

Shared tier

Private tier

Suite tier

or whatever is available for immediate move in

Employment

Are you currently employeed?

Yes

No

full time or partime and how many hours a week?

Please list

hourly pay rate,

employeers name

employees address

Pay distribution

Weekly

Bi-weekly

Monthly

Other

N/A

If unemployed why is the source of income ?

Please list all sources of income .

How much do you receive monthly ?

Next pay date?

Do you have identification? Birth Certificate? Social Security? veteran ID

Ie: homeless ID is suffecient but must be updated

When are you planing to move in?

Please note: that there is a one time $300 program fee when entering the program and will be do along with the montly rent. Rent will be prorated based on the date of move-in if necessary.

Intake Form

Information Pages

FAQs

About

Contact

Contact Information

(910) 818-2480

admin@infinitechancesconsulting.net