Bliss Health Care

Shared Living — Client Intake Form

+717 467 1635

[email protected]

www.blisshealth-care.com

Bliss Health Care

Shared Living — Client Intake Form

Personal Housing Income & Benefits Medical Background Emergency Contact Referral Notes

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Personal InformationRequired

First Name*

Last Name*

Date of Birth*

Gender

Phone Number*

Alternate Phone

Email Address

Social Security Number*Format: 000-00-0000 — handle with confidentiality

Ethnicity

Primary Language

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Housing History & Current SituationRequired

Current Living Situation*

Homeless / UnshelteredEmergency ShelterTransitional HousingHospital / FacilityStaying with OthersOther

How long without stable housing?

Last Permanent Address (City)

Reason for Losing Housing

Desired Move-In Date

Preferred Bliss Home

Previous Evictions or Landlord Issues?

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Income & BenefitsRequired

Current Income Sources (select all that apply)

SSISSDIGeneral ReliefEmploymentVeterans BenefitsPensionNo Income

Monthly Income Amount

SSI/SSDI Application Status

Current Benefits (select all that apply)

MedicaidMedicareSNAP / EBTVA BenefitsIHSSNone Currently

Medicaid Status

Medicaid ID Number

Has Rep Payee?

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Medical & Mental Health HistoryRequired

⚠️This section is confidential. Collect only what is necessary for placement and care planning. Do not share without written consent.

Diagnosed Mental Health Conditions (select all that apply)

DepressionBipolar DisorderSchizophrenia / PsychosisPTSDAnxietyADHDTBIOtherNone Reported

Substance Use History

AlcoholMarijuanaMethamphetamineOpioids / HeroinCrack / CocaineIn RecoveryNone Reported

Date of Last UseMost recent date of any substance use

Currently in Treatment / Sober Living?

Currently on Medication?

Currently in Mental Health Treatment?

Physical Health / Disabilities

Recent Hospitalization?

Discharging From

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Criminal BackgroundRequired

⚠️A criminal history does not automatically disqualify a client. Collect information honestly to ensure proper placement and house rules compliance.

Any Criminal History?*

NoYes – MisdemeanorYes – FelonyYes – Both

Currently on Probation or Parole?

Probation / Parole Officer Name

PO Phone Number

Sex Offender Registry?*

NoYes

Arson History?

NoYes

Criminal History Notes

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Emergency Contacts & ReferencesRequired

Emergency Contact Name*

Relationship

EC Phone Number*

EC Email

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone

2nd Contact Email

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Referral SourceRequired

Referral Type*

Referring Organization

Referring Person (Name)

Referral Person Title

Referral Phone

Referral Email

Referral Notes

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Staff NotesOptional

Staff Member Taking Call

Call Date & Time

General Intake Notes

Placement Decision

ApprovedPending ReviewWaitlistDenied

Ready to save this intake?

All required fields must be completed before submitting.

Client Signature

Date

Staff Signature

Date

Bliss Health Care · +717 467 1635 · [email protected] · www.blisshealth-care.com

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Intake Submitted!

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