Housing Referral & Intake Form -

REVIVING HOPE HOMES
Housing Referral & Intake Assessment Form
Restoring Hope. Rebuilding Lives. Renewing Futures.

1. Applicant Information

Applicant First Name *

Applicant Last Name

Phone Number

Email Address *

Emergency Contact Name *

Last Known Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

2. Current Housing Situation

Reason for Seeking a New Place to Stay

Desired Move-In Date

3. Independent Living Assessment

Are you able to manage your daily routine independently? *YesNo

Are you able to bathe, dress, groom, eat, and use the restroom independently? *YesNo

Are you able to clean and maintain your living space? *YesNo

Are you able to cook or prepare basic meals? *YesNo

Can you safely be left alone and evacuate the home independently in an emergency? *YesNo

If assistance is needed, please explain

Are you able to manage your own transportation needs? *YesNo

Do you use a wheelchair, walker, cane, or other mobility aid? *YesNo

Accessibility accommodations needed

4. Shared Living

Are you comfortable living in a shared-home environment? * *YesNo

Are you willing to respect other residents' privacy, belongings, and personal space? *YesNo

Are you willing to participate in reasonable household chores? *YesNo

Are you willing to follow the home's rules regarding visitors and overnight guests? *YesNo

Are you willing to follow established house hours/curfew requirements, unless otherwise approved? *YesNo

5. Employment, School & Programs

Are you currently working, attending school, or participating in a community/program service? * *YesNoLooking for oppurtunities

If yes, please describe

6. Medication & Support Needs

Do you currently take prescribed medication? * *YesNo

Can you manage and take your medications independently? * *YesNoNot Applicable

Do you currently receive outside support services, such as a case manager, counselor, home-health provider, or other community support? *YesNo

If yes, please describe the type of support

Do you have a health condition or limitation that could affect your ability to live independently or safely in a shared home? *YesNo

If yes, describe the support or accommodation needed (detailed medical history is not required)

7. Substance Use & Home Environment

Do you currently use alcohol? *YesNo

Do you currently use marijuana? *YesNo

Do you currently use other non-prescribed drugs? *YesNo

Do you currently use nicotine or tobacco products? *YesNo

Are you willing to comply with Reviving Hope Homes' drug-, alcohol-, and smoke-free housing rules? *YesNo

Are you currently participating in, or have you previously participated in, a substance-use treatment/recovery program? *YesNo

If yes, and you choose to provide details

8. Safety Assessment

Is there any recent behavior or safety concern that could affect the safety of you, another resident, or the shared-home environment? *YesNo

If yes, please explain

Is there additional support you believe you would need to live successfully at Reviving Hope Homes?

9. Income & Financial Information

Do you currently have a source of income? * *YesNo

Approximate Monthly Income * *

Are you able to meet the monthly housing/program fee? *YesNoUnsure

Do you have financial obligations that may affect your ability to make your housing payment? *YesNo

If yes, please explain *

10. Verification Documents

Proof of Income: Attach a recent pay stub, benefit letter, award letter, or other acceptable proof of income.
Government-Issued Identification: Attach a valid government-issued ID.

11. Housing History

Previous Landlord or Housing Provider

Previous Landlord/Housing Provider Phone or Email

Reason for Leaving Previous Residence

12. Additional Information

Is there anything else you would like Reviving Hope Homes to know when considering your housing needs?

13. Applicant Acknowledgment

Applicant/Representative Name

Signature *

Date

14. Communication Consent