Client Intake Form — Jordan Crossing Recovery Homes

Personal Information

Required

First Name *Last Name *Date of Birth *Gender Phone Number *Alternate Phone Email Address Social Security Number *Format: 000-00-0000 — handle with confidentialityEthnicity Primary Language

Housing History & Current Situation

Required

Current Living Situation *

How long without stable housing? Last Permanent Address (City) Reason for Losing Housing Date of Lost Housing Preferred Jordan Crossing Home Desired Move-In Date Any prior stays in recuperative care or STPHH in the last 12 months Previous Evictions, Landlord Issues, or Recuperative Care Details

Income & Benefits

Required

Medical & Mental Health History

Required

Criminal Background

Required

⚠️ 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

Emergency Contacts & References

Required

Emergency Contact Name *Relationship EC Phone Number *EC Email 2nd Contact Name 2nd Contact Relationship 2nd Contact Phone 2nd Contact Email

Referral Source

Required

Referral Type *Referring Organization Referring Person (Name) Referral Person Title Referral Phone Referral Email

Referral Notes

Staff Notes

Optional

Staff Member Taking Call Call Date & Time

General Intake Notes Placement Decision

ApprovedPending ReviewWaitlistDenied