top of page
First Name
*
Last name
*
Birthday
*
Month
Month
Day
Year
Age
*
Gender
*
Female
Male
Phone
*
Email
Legal US 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) where common areas like the kitchen, living room and bathroom are shared with other unrelated 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? Dates? Where?
*
Do you have a legal history? Arrest? Charges? Time Served?
*
Yes, not currently on probation
Yes, currently on probation
No
Any history of aggression or violent behavior?
*
Yes
No
Have you been charged with any sexual misconduct?
*
Yes
No
If yes, provide date and details. If no, indicate 'N/A.'
*
Do you use drugs and/or alcohol?
*
Yes
No
If yes, date of last use? Indicate N/A if not applicable
*
Do you use tobacco, nicotine, or vaping products?
*
Yes
No
Do you currently receive Social Security benefits such as Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)?
*
Yes
No
Do you receive Medicaid and/or Medicare?
*
Yes
No
What is your monthly income?
*
Is an agency or organization providing rental assistance to you? If so, what agency?
*
What are your goals and how can we help you to achieve them?
*
Submit
bottom of page
