Lead Assessment

Begin your new chapter.

All information is confidential and reviewed with compassion. Fields marked * are required.

— Getting to know you

First and last name *

If you're interested in moving forward, may I begin the assessment to confirm eligibility? *

— Funding & move-in

Do you have a case manager that recommended you? If yes, please provide their name, number, email, and organization. *

Main income source (VA, SSI, SSDI, Employment, Family, etc.) and monthly amount? *

Are you receiving funding assistance for your move-in costs from an organization? *

Desired move-in date *

Are you able to pay first month's rent on the day of your move-in? (Second month is prorated if you move in after the 3rd.) *

— Personal information

Best phone number *

Date of birth *

Last 4 digits of SSN (for background check) *

Height / Weight *

Have you lived in a room and board or residential program before? Please share the contact info and address of your most recent home. *

Reason for leaving: *

Do you possess a driver's license or ID? If yes, please be prepared to provide a copy. *

Do you receive government assistance (EBT / Cash Aid)? If yes, please list. *

Emergency contact information *

— Health & wellness

Do you have any physical health conditions? *

Do you have any special needs or assistance required for daily living? *

Do you have any mental health diagnoses? (e.g., bi-polar, schizophrenia) *

Are you medication-compliant? When were you last off your meds, and what happened? *

Are you currently taking any medications? Which ones? Do you need medication reminders? *

Any known allergies? *

Current medical insurance *

Have you ever experienced thoughts of self-harm or suicide, or attempted suicide? If yes, please share details. *

— Background

Have you ever been arrested, charged, or convicted of a crime or felony? Please include where, when, charge, and time served. *

Have you ever used Marijuana, Methamphetamine, Opioids, Opiates, Heroin, Fentanyl, or any controlled/street drug? If yes, please explain and share your last use. *

Do you use alcohol? How frequently? *

Do you use tobacco? *

Your information stays private and is never shared without your consent.