Apply Now – Hope Restored Supportive Housing

Hope Restored Supportive Housing

Serving Charlotte County, FL and Surrounding Counties

(941) 267-7445
admin@hoperestoredsl.com

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Apply Now

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Fill the Intake Form

Supportive Housing Client Intake Form

Thank you for your interest in Hope Restored Supportive Housing.

This intake form helps us determine eligibility for our independent supportive housing program.

Submission of this form does not guarantee placement. A member of our team will contact you after reviewing your application.

Intake Information

Date of Intake:

Date Housing Needed:

Participant Information

Applicant Full Name:

Date of Birth:

Age:

Social Security Number (Last 4 Digits):

Phone No:

Email Address

Gender

Male Female Non-Binary Prefer Not To Say

Emergency Contact Name:

Relationship to Applicant:

Emergency Contact Phone:

Current Living Situation

What is your current living situation?

Homeless Staying with friends/family Shelter Own/Rent housing (at risk of losing) Hospital/Rehab Transitional Housing Jail/Prison Release Other:

If other:

Briefly describe why you are seeking supportive housing:

Referral Source (If Applicable

Referral Type

Self Agency Parole/Probation Hospital/Treatment Center Family/Friend Other:

If other:

Referring Contact Name:

Referring Phone Number:

Income Information

Source of Income

SSI/SSDI Veterans Benefits Employment Retirement/Pension

Monthly Income Amount:

Medical and/or Mental Health History (If Applicable)

Substance Abuse History

Alcohol Drugs None Other

If other:

List Any Mental Health Diagnosis:

Legal Background

Are you currently on parole or probation?

Yes No

Are you a registered sex offender?

Yes No

Housing Preferences or Needs

Do you require specific accommodations?

Yes No

If yes, specify accommodations:

Preferred Room Type

Shared Room Private Room (If Available) Any Available

Independent Living & Functionality Acknowledgment

Our program provides independent supportive housing. Residents must be able to manage daily living tasks including hygiene, meals, medication management, transportation, housekeeping, and responsibilities.

Can you live independently and manage Activities of Daily Living (ADLs)?

Yes No

If No, please explain:

Do you have or need a Home Health Care Provider or Outside Support Service?

Yes No

If Yes, list Agency Name:

Is there anything else you would like us to know?

Program Agreement & Declaration

I understand this program provides housing only and I am responsible for my personal care, medical needs, and daily living tasks.

Agreement

I Agree (I certify that the information provided is true and correct. I understand that submission of this intake form does not guarantee placement.)

Applicant Name:

Applicant Signature:

Date:

At Hope Restored Supportive Housing, we provide affordable shared housing in a quiet, clean, and secure environment designed to promote independence, accountability, and community.

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(941) 267-7445

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admin@hoperestoredsl.com
(941) 267-7445
Serving Charlotte County, FL and Surrounding Counties

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