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INTAKE FORM | YORK STREET COMMUNITY LIVING
First name
*
Last name
*
Phone
*
Email
*
Multi-line address
Country/Region
*
Address
*
Address - line 2
City
*
Zip / Postal code
*
Best Time To Reach You
*
Morning
Afternoon
Evening
Gender
*
Male
Female
Birthday
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Month
Day
Year
Social Security Number
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Race/Ethnicity
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Caucasian
African-American
Latin X
Other
Do you identify as a member of the LGBTQ+ community?
*
Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.*
*
Yes
No
Do you have any criminal convictions pending? Please note, answering yes does not automatically disqualify you.*
*
Yes
No
City and state of conviction
If you answered yes to the above questions, please explain:
Are you transitioning from any of the following situations?
*
Homelessness
Rehabilitation
Substance Abuse Recovery
Recently Incarcerated
Domestic Violence Shelter
Mental Health Facility
None
Other
Do you currently have a case manager, social worker, or program contact?*
Yes
No
If yes, please provide their name and contact info
Do you currently or have you ever used any illegal substances?*
Yes
No
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