Resident Intake Form | Serenity Haven independence home

Put N/A for any info that may not pretain to you

Date of Intake *

Full Name *

Date of birth *

Email *

Gender *

Male
Female
Other
Prefer not to say

Social Security *

Emergency contact Name, Relationship, phone number *

Phone number *

Have you experienced homelessness? *

Yes
No

If yes, how long have you been without stable housing? *

Less than 6 months
6-12 months
Over a year

Where did you stay last night? *

Shelter
Street
Hospital
Jail
Transitional housing
Other

Do you have any medical conditions *

Yes
No

If yes list medication(s) *

Do you have any mental health diagnosis *

Yes
No

If yes list here *

Substance use history *

Drugs
Alcohol
None

Are you recovering *

Yes
No

Are you on parole or probation *

Yes
No

If yes Name of officer and phone number *

Do you have pending legal cases *

Yes
No

If yes explain *

Source of income check all that apply *

SSI/SSDI
Employment
Veterans benefits
General assistance
Unemployment
None
Other

Monthly income amount? *

what are your short term goals while living at Serenity Haven? *

Do you need help in the following (check all that apply) *

Finding employment
Managing Finances
Accessing Healthcare
Mental health support
Daily living Skills
Reconnecting with family

Additional Concerns *

Resident Signature *

Date *

Staff Signature

Date

Leave this field empty

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