BR
Bethel Residency
Client Intake Form · Staff Portal
Personal
Housing
Income & Benefits
Medical
Background
Emergency Contact
Referral
Notes
👤
Personal Information
Required
▾
First Name
*
Last Name
*
Date of Birth
*
Gender
Select...
Male
Female
Non-binary
Prefer not to say
Other
Phone Number
*
Alternate Phone
Email Address
Social Security Number
*
Format: 000-00-0000 — handle with confidentiality
Ethnicity
Select...
Hispanic / Latino
Black / African American
White / Caucasian
Asian / Pacific Islander
Native American
Two or More Races
Other
Prefer not to say
Primary Language
Select...
English
Spanish
Other
🏠
Housing History & Current Situation
Required
▾
Current Living Situation
*
Homeless / Unsheltered
Emergency Shelter
Transitional Housing
Hospital / Facility
Staying with Others
Other
How long without stable housing?
Select...
Less than 1 month
1–3 months
3–6 months
6–12 months
1–2 years
2+ years
Chronically homeless
Last Permanent Address (City)
Reason for Losing Housing
Select...
Eviction
Financial
Domestic Violence
Substance Use
Mental Health
Incarceration
Hospitalization
Other
Desired Move-In Date
Preferred Bethel Home
No preference / Any available
Walking Beam Dr
Manfield St
Grand Ave
775 Libby Dr
782 Libby Dr
Previous Evictions or Landlord Issues?
💰
Income & Benefits
Required
▾
Current Income Sources (select all that apply)
SSI
SSDI
CalWORKs
General Relief
Employment
Veterans Benefits
Pension
No Income
Monthly Income Amount
SSI/SSDI Application Status
Select...
Currently Receiving
Pending / Applied
Denied – Appealing
Never Applied
Needs Assistance Applying
Current Benefits (select all that apply)
Medi-Cal
Medicare
CalFresh / EBT
VA Benefits
IHSS
None Currently
Medi-Cal Status
Select...
Active
Pending
Lapsed / Needs Renewal
Never Had
Needs Assistance Applying
Medi-Cal ID Number
Has Rep Payee?
Select...
Yes
No
Needs One
🏥
Medical & Mental Health History
Required
▾
⚠️
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)
Depression
Bipolar Disorder
Schizophrenia / Psychosis
PTSD
Anxiety
ADHD
TBI
Other
None Reported
Substance Use History
Alcohol
Marijuana
Methamphetamine
Opioids / Heroin
Crack / Cocaine
In Recovery
None Reported
Date of Last Use
Most recent date of any substance use
Currently in Treatment / Sober Living?
Select...
Yes – Outpatient Program
Yes – AA / NA
Yes – MAT (Medication Assisted)
Completed Treatment
No – Not in Treatment
N/A
Currently on Medication?
Select...
Yes – Psychiatric
Yes – Medical
Yes – Both
No
Currently in Mental Health Treatment?
Select...
Yes – Outpatient
Yes – Case Management
Recently Discharged
No
Needs Referral
Physical Health / Disabilities
Recent Hospitalization?
Select...
Yes – Psychiatric
Yes – Medical
Yes – Both
No
Discharging From
⚖️
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?
*
No
Yes – Misdemeanor
Yes – Felony
Yes – Both
Currently on Probation or Parole?
Select...
No
Yes – Probation
Yes – Parole
Yes – Both
Probation / Parole Officer Name
PO Phone Number
Sex Offender Registry?
*
No
Yes
Arson History?
No
Yes
Criminal History Notes
🆘
Emergency Contacts & References
Required
▾
Emergency Contact Name
*
Relationship
Select...
Parent
Sibling
Spouse / Partner
Child
Friend
Case Manager
Other
EC Phone Number
*
EC Email
2nd Contact Name
2nd Contact Relationship
Select...
Parent
Sibling
Spouse / Partner
Child
Friend
Case Manager
Other
2nd Contact Phone
2nd Contact Email
📋
Referral Source
Required
▾
Referral Type
*
Select...
Hospital / ER
Mental Health Clinic
Nonprofit / CBO
Social Worker
Case Manager
Housing Navigator
Probation / Parole
Self-Referral
211
Other
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
Approved
Pending Review
Waitlist
Denied
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