Name * First Name Last Name Email Phone * (###) ### #### Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Female Male Date of Birth * MM DD YYYY Do you have an ID card? * Yes No Do you have a Social Security Card? * Yes No Social Security Number (if you don't have one, please put N/A) * Do you have a Drivers License? * Yes No Drivers License Number (if you don't have one, please put N/A) * When do you need housing? Immediate (< 2 weeks) 1 month 2 months 3 months What date do you need housing to start? * MM DD YYYY What organization is helping you (if none, please put N/A) * Do you have a Case Manager? Yes No If you checked Yes, please list your Case Manger's name Emergency Contacts/Family or Friends - Names and Numbers (provide at least 2) * Are you a Veteran? * Yes No Income Status * Working DOC Housing Voucher HARP Funding SSI SSDI Other If you checked Other, please explain Please tell us about any other income here Do you currently have a job? * Yes No If you do not have employment, what are your plans to get a job? What type of work? Do you plan on attending school or training? What type of education? Do you have a car? * Yes No Healthcare * Medicaid State Health Both None Other If you checked Other, please explain Any Mental Health services or medication in past or present? Please list (if not, please put N/A) * Any Chemical Dependency in past or present? Do you receive services? Where? (if none, please put N/A) * Please list any prescription medications you are taking (if none, please put N/A) * Do you have any allergies (if none, please put N/A) * Debt or Legal Financial Obligations? * Yes No If you checked Yes, please explain Have you ever lost housing? Why? Do you have children? * Yes No If you checked Yes, please explain (list how many and ages) Incarceration or arrest history? * Yes No If you checked Yes, please explain Charges pending? Yes No What county/city are the pending charges in? Status of pending charges? Probation Officer Name What are your goals and plans? * Why do you want to live at Solid Ground House? Why have you chosen this type of housing option? * What else should we know about you in order for us to better assist you? * Consent to Procedures * Solid Ground House requires random urinalysis tests in the house and as a condition to entry to the house and remaining in the program. We do not require access to medical information, unless there is an emergency in the house, Or you are on medication prescribed by a physician or on a medically assisted treatment for addiction. I consent to random urinalysis testing Thank you! Client Intake Form
