Forward Living Solutions Client Intake Form

"In accordance with Texas guidelines, we provide independent living housing for self-sufficient adults. We are not a licensed provider of personal care, assisted living, or medical services, and our homes do not function as treatment facilities.

Our supportive housing communities serve individuals—including veterans, seniors, domestic violence survivors, and those transitioning from unstable housing—who are capable of living independently without the need for daily medical or personal care."

Instructions: Please fill out this form to the best of your ability. Your information will help us assess your needs and effectively assist you. All information is kept confidential.

Sign in to Google to save your progress. Learn more
This form is being completed by: *
Required
Name *
First and last name
Email *
Phone number *
Date of Birth and Age: *
Current Address: (Street, City, State, Zip Code) *
Emergency Contact: 
(Name, Phone #, Relationship to Client)
 *
Military/Veteran Status 
Are you a Veteran ?
 *
Housing Program Needs 

Current Housing Situation:
 *

Desired Move-in Date:


 *

How long will you need shared living support ?

 *

Do you have any specific housing preferences or requirements?

(e.g., single unit, accessibility features, etc.):

 *

Health Assessment

Please List all Medical Diagnosis/Condition(s):

 *

Please List all medications including prescription and over the counter:

 *
Are you able to take medications without assistance? *
Are you able to walk without a wheelchair, walker or cane? *
Are you incontinent? *
Have you been hospitalized within the last 12 months? *

Safety & Mental Health Assessment

Do you feel safe in your current living situation? *

Have you experienced any of the following in the past 12 months?

 *

Are you currently receiving mental health support or services?

 *

If yes, please specify the type of support

(e.g., therapist, counselor):

 *

Do you have any specific mental health concerns or conditions?

 *

Have you previously been involuntarily committed ?

 *
Social and Legal History

Do you have any of the following?
 *
Required
Insurance & Financial Resource

Do you have any of the following?
 *
Required
Do you receive social security benefits? *
What is your monthly income ($) ? *
EMPLOYMENT STATUS: *
Required
Additional Support & Resources

What type of support do you feel you need most at this time ?

(e.g., housing, mental health services, financial counseling, job training):

 *
Are there any other challenges you are currently facing that we should be aware of ? *
Consent and Signature

TODAYS DATE:
 *
MM
/
DD
/
YYYY

By typing your name below, you consent to the collection and use of your information by Forward Living Solutions for the purpose of assessing your housing needs and connecting you with appropriate services.


 *

If Completed By Case Manager or Representative:

Please Provide Name and Title/Relationship to Client


Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of faithicc.org.

Does this form look suspicious? Report

Google Forms