Cherylann Safe Horizon Independent Living – Intake Form

Thank you for your interest in Cherylann Safe Horizon Independent Living. To join our waitlist, please complete the intake form below.

  • Shared rooms start at $850/month

  • Private rooms start at $950/month

  • Sliding scale rates may be available and are assessed on an individual basis

Depending on your circumstances, we may request the following documentation:

  • Verification of a mental health diagnosis

  • A list of any prescribed medications

  • Proof of enrollment in an outpatient drug treatment program

If you have any questions, please don’t hesitate to call or text (410) 622-0872 or email us at cherylannsafehorizon.com. We’re here to support you.


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Client First Name*
Client Last Name*
Client Date of Birth - Use the MM/DD/YEAR *
Gender Assigned At Birth *
Martial Status *
Race *
Participant Email Address *
Participant Phone Number *
Do we have permission to text the phone number provided?
Current Living Situation *
If homeless, please explain how long.
How will participant pay for housing? 
Please note: Award letter or Proof of income will be required during intake process.

Participant monthly income? If none, type "None"
Explain your Income Source(s). For example, SSI or Job Name. *
Are you on parole/probation, or have any current legal proceeding?*
Clear selection
Would you need any of the below case management services?
How did you hear about us?
Are you a Veteran? If so, please indicate branch of service*
Are you a registered sex-offender?*
Does the participant have a history of criminal justice involvement? 
*** Please note: The answer to this question are for program support and planning purpose only. Responses will not determine eligibility or disqualify the participant from the program.



Does the participant have any disabilities that we should be aware of to provide appropriate support? *
   A disability is a physical or mental condition that may limit a person’s movements, senses, activities, or ability to care for themselves. Disabilities can be visible or invisible, temporary or long-term. Examples include mobility impairments, vision or hearing loss, developmental or intellectual disabilities, chronic illnesses, mental health conditions, or learning disabilities.  (If yes, please explain. If no, please type "no") 
Is the participant independent?*
  Being independent means the participant is able to manage their own daily activities without needing hands-on help from another person. This includes essential activities of daily living (ADLs) such as bathing, dressing, grooming, eating, using the bathroom, and moving around safely. An independent participant can take care of these needs on their own and does not require regular physical assistance, though they may still benefit from optional support, companionship, or community services.  
Yes, The participant does not require assistance with ADLs.
No, The participant does need assistance with one or more ADLs.
Other:

Does the participant have any mental health
 history , or medical conditions we should be aware of to provide appropriate support?

Does the participant take any medications related to the health conditions or concern noted above?
(If yes, a detailed list will be requested during the intake process.)


Does the participant require handicap accessibility?
Does the participant currently or previously have a history of substance use (such as alcohol, tobacco, or other drugs)? choose all applicable.*
If other, please explain
Does the participant need assistance with alcohol  or substance abuse recovery?
Anything else you would like us to know?
Representative Name, Phone number, Organization an Relationship (or title)
An organization is any agency, group, or program that provides service or support to the participant. Example include the Veterans Affairs (VA), case workers, probation or parole officer, the renewal center, local mission programs, community health clinics, and other nonprofit or faith-based organizations in Maryland. 


In addition to the above representative,
 does the participant have a support team?
  A support team means the people who provide help, guidance or assistance to the participant. This may include family, friends, a payee, spouse, sponsor, or other trusted individual involved in their care or daily life.

Desired Move in Date *
Date:
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