Intake Form | AlayaHealth

Housing Intake Form

Fill out the short questionnaire below to begin the admissions process. This questionnaire helps us understand your current concerns and provides our admissions team with important background information.

Client's Name

Client's Gender

Email

Phone

Representative's Name and Organization (ex. HUD, VA etc,}

Client's Date of Birth

Month

Day

Year

Client's Current Living Situation

Room Preference

Private Room

Shared Room

When Does Client Need To Be Placed

Client's Monthly Income? If None, Please Type NONE.

Does Client Suffer From A Mental Illness?

Yes

No

If Yes, Enter Mental Diagnosis

Does Client Require a Handicap Accessible living Environment?

Yes

No

Is Client an Ex-Offender

Yes

No

Has Client Been Convicted As A Sex Offender?

Yes

No

With 1000ft restriction

Without 1000ft restriction

Is Client Currently on Probation or Parole?

Yes

No

Please Include Any Important Information Relevant to This Application Below

Please Upload Proof of Income

Please Upload Copy of Identification

Personal Reference #1

Personal Reference #2

Housing Intake Form

Alaya House