Intake Screening Form Please enable JavaScript in your browser to complete this form.Resident's Name *FirstLastResident's Email *Resident's Phone *Resident's Mailing Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeResident's Age *Resident's Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Resident's Gender *FemaleMalePrefer not to discloseIs resident able to pay for housing at this time? *YesNoIs resident able to pay the $150 deposit? *YesNoCan resident speak, write and understand English? *YesNoWhy is the resident seeking housing at this time? *What strengths does the resident possess? *What preferences does the resident have? *What goals does the resident have? *Date of resident's last physical health screening (can be approximate) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was the outcome of the last physical health screening? *Do you have a history or diagnosis of an eating disorder? *Date of residents last use of drugs/alcohol (can be approximate) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does resident need detox before admittance? *YesNoDoes resident have any disabilities that could affect participation in housing (deaf, blind, etc.)? *Does resident have any prior psychiatric history (please explain)? *Resident must be stable prior to starting treatment and can not be actively suicidal, homicidal or psychotic.Has resident recently been hospitalized (please explain)? *Has resident tested positive for TB? *YesNoCurrent medications *Are you filling this application on residents behalf? *YesNoYour Name *FirstLastRelationship to resident *Do you have a power of attorney/surrogate decision maker or guardianship of resident? *YesNoType your name as a signature *Resident: Type your name as signature *CommentSubmit