Step Toward Your Fresh Start

Resident Intake Form

Please complete this form honestly and thoroughly.
All information is kept confidential and used solely to find the right housing fit for you.

Intake Form – Client Information and Consent

Date *

Referral Agency

Client Information

Client Information

Client Name *

Date of Birth (DOB) *

Street Address

Apartment, suite, etc

City

State / Province

ZIP / Postal code

Country

Gender *MaleFemale

Emergency Contact

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Relationship to Client

Current Living Situation

Current Living Situation

Current Living Situation (select all that apply) *HomelessCouch SurfingStaying with othersJail / PrisonHospital / RehabTransitional HousingOther

If 'Other', please specify

Background Information

Background Information

Are you currently on probation or parole? *YesNo

Are you a registered Sex Offender? *YesNo

How did you hear about us?ReferralWebsiteSocial MediaOther

Brief Summary of Your Situation / Reason for Housing Needs *

Medical / Mental Health History

Medical / Mental Health History

Medical Condition / History 1

Medical Condition / History 2

Medical Condition / History 3

Medical Condition / History 4

Mental Health Diagnosis Heading

Mental Health Diagnosis

Includes any substance abuse, drugs, or alcohol

Mental Health Diagnosis 1

Mental Health Diagnosis 2

Mental Health Diagnosis 3

Mental Health Diagnosis 4

Income Information Heading

Income Information

Must show proof of income

Income Source(s)SSISSDIEmploymentOther

Housing Preferences Heading

Housing Preferences / Needs

List any disabilities or accommodation needs

Housing Need / Accommodation 1

Housing Need / Accommodation 2

Notice

Important Notice: This program supports individuals who are able to live independently. This is not a personal care home, nursing home, or assisted living setting. We do not offer medical care, personal care, or supervision. You must be able to manage your own daily needs.

Goals / Expectations

Goals / Expectations

Please explain your main goals, challenges, or concerns

Personal Care Heading

Personal Care / ADL’s

If you require medical or personal care services, it must be provided by a licensed medical agency or caregiver – arranged and paid separately. A doctor’s order must be provided.

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

Do you currently have or need a home healthcare provider or outside support services? *YesNo

Personal Care Acknowledgment *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.

Signature – Personal Care Section (type full name) *

Date – Personal Care Section *

Program Agreement Preview

Program Agreement Preview

House Rules Agreement *I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.

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

Application Declaration Heading

Application Declaration

I verify 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.

Print Name *

Applicant Signature (type full name) *

Consent and Agreement Heading

Consent & Agreement

I AGREE TO ALL ABOVE STATEMENTS LISTED. I AGREE THAT VIOLATING WILL RESULT TO DISMISSAL.

Final Signature (type full name as consent) *

Date *

Please do not fill in this field.

What Happens Next?

Form Reviewed

We review within 24–48 hours

We Call You

A staff member will reach out

Move-In Day

Easy, stress-free process

Need Help?

We’re here for you. Call or email and we’ll walk you through every step.

📞 316-553-6943

✉ reclaim22@yahoo.com

All data is private & confidential

Our Promise

“Let Us Partner With You”

We walk alongside every resident — judgment-free, every step of the way.