Secure Housing Intake

Please provide accurate information. This secure form is transmitted directly to our clinical and housing teams.

1. Contact Information

First Name

Middle Name

Last Name

Preferred Name / Alias

Phone Number

Email Address

Confirm Email Address

Referral Source

Additional Notes

Contact Consent I consent to be contacted via text, email, or phone.

2. Legal Identity

Full Legal Name

Date of Birth

SSN

Current Employment Status

ID Type

ID Number

Issuing State

Physical ID in hand?

Do you have a DOC number?

DOC Number

Name on DOC Documents

Background Check Consent I authorize Pathway2Progress to conduct a background check.

3. Professional References

Ref 1 Name

Relationship

Phone

Ref 2 Name

Relationship

Phone

4. Demographics & Identity

Race / Ethnicity

Sex at Birth

Sexual Orientation

Relationship Status

Preferred Language

Veteran Status

5. History & Wellness

Reason for seeking housing

Address History (Last 3 Years)

Primary Wellness Concern (Substance, etc.)

Date of Last Instance

Mental Health History?

History of Self-Harm?

Current Prescription Medications?

Location Preference

6. Legal & Safety

Gang Affiliation History?

On Sex Offender Registry?

Ever Charged with Arson?

Known Housing Restrictions?

Desired Move-In Date