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Name
*
Birthday
*
Month
Month
Day
Year
Age
*
Phone
*
Email
Legal Resident
*
Yes
No
How did you hear about Noah’s Ark Housing?
*
Do you understand Noah’s Ark Housing provides affordable housing to individuals (not families) in a shared living environment with other residents?
Yes
No
Where are you currently living?
*
What is your mental health diagnosis?
*
Provide the name and dosage of your medications.
*
Have you received any mental health treatment or drug rehabilitation treatment? Where? If no, enter N/A?
*
Any recent hospitalizations?
*
Reason for treatment?
*
Any medical conditions or physical health problems?
*
Are you incontinent or have bladder issues?
*
Yes
No
Have you been Baker Acted before? When? Where?
*
Do you have a legal history? Arrest? Charges? Time Served?
*
Yes
No
Any history of aggression or violent behavior?
*
Yes
No
Have you been charged with any sexual misconduct?
*
Yes
No
Do you get upset or frustrated easily?
*
Do you use drugs and/or alcohol?
*
Yes
No
Date of last use? Indicate N/A if not applicable
*
Do you use nicotine products?
*
Yes
No
Do you receive Social Security benefits?
*
Yes
No
Do you receive Medicaid or Medicare?
*
Yes
No
What is your monthly income?
*
Does someone or your family provide support?
*
What are your goals and how can we help you to achieve them?
*
Submit
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