Intake Form – Larry’s Safe Haven

First Name

Last Name

Gender

Male Female

Date of Birth

Phone Number

Do we have the permission to call the number above?

Yes No

Best time to reach you?

Morning Afternoon Evening Anytime

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

Housing History

Which best describe you?

How long have you been in this situation?

Client's Current Address

Reason for seeking Housing?

Have you ever been evicted?

Yes No

If yes, please provide details

Background & Legal History

Are you currently on parole or probation?

Yes No

If yes, please provide details (e.g. Probation Officer Full Name and Contact Information)?

Have you been convicted as a Sex Offender?

Yes No

If yes, please provide details

Have you been convicted of a felony in the last 10 years?

Yes No

If yes, please provide details

Are there any pending criminal charges against you?

Yes No

If yes, please provide details

Have you ever been charged with a violent crime?

Yes No

If yes, please provide details

Health & Support (Confidential)

Do you currently receive services from a caseworker, counselor, or community agency

Yes No

If yes, please provide details

Do you have any disabilities or special needs?

Yes No

If yes, please provide details

Do you have any history of substance abuse?

Yes No

If yes, please provide details

Do you have any medical conditions that require ongoing treatment or monitoring?

Yes No

If yes, please describe your disabilities or special needs?

Do you take any prescribed medications?

Yes No

If yes, please provide details

Do you have any mental health conditions?

Yes No

If yes, please provide details

Do you have any mobility or accessibility needs (e.g., wheelchair access, stair limitations)?

Yes No

If yes, please provide details

Employment & Income

Monthly Income Amount

Can you provide proof of income?

Yes No

Do you have a representative payee?

Yes No

If yes, please provide details

Housing Preferences

When does the client need to be placed?

Desired Length of Stay

Room Type Preferred

Shared Room Private Room No Preference

Do you have any concerns about living with others (e.g., age, gender, habits)?

Are you open to scheduled room inspections to maintain property standards?

Yes No

Do you currently have furniture or personal belongings that will need space (Clients are only allowed 2 personal bags)?

Yes No

If yes, please provide details

Agreement & Acknowledgment

Are you willing to follow house rules and expectations (e.g. no smoking in house, no unapproved guests, quiet hours, cleanliness)?

Yes No

Are you able to live independently without daily assistance?

Yes No

I understand this is an independent living program, not assisted living.

Yes No

Larry’s Safe Haven, is a drug- and alcohol-free environment. Do you agree to follow this policy?

Yes No

I acknowledge that participation is based on month-to-month terms and ongoing compliance with program guidelines.

Yes No

I agree to pay rent on time as outlined in my housing program agreement.

Yes No

I agree to follow all house rules and understand repeated violations may result in termination of my housing.

Yes No

I acknowledge that Larry’s Safe Haven, is not liable for my personal belongings.

Yes No

I certify that the information I have provided is accurate and truthful to the best of my knowledge.

Yes No

Typed Signature

Today's Date

Next Steps After Submission

Thank you for your interest in Larry’s Safe Haven. Our current housing rates are based on room type and location. Rates start at $750/month for shared accommodations. Once your application is reviewed, a member of our team will contact you to discuss availability, pricing, and next steps. Please note: This form adds you to our priority interest list and current waitlist. Placement is offered based on availability, program fit, and the order in which applications are received.

Housing Intake Form

Housing History

Background & Legal History

Health & Support (Confidential)

Employment & Income

Housing Preferences

Agreement & Acknowledgment

Next Steps After Submission