Intake Form

Section 1 — Personal Information

• Full Name

• Date of Birth

• Phone Number

• Email Address

• Current Living Situation (Short answer — “Where are you staying right now?”)

Section 2 — Program Interest

• What type of support are you seeking?

  • Residential Care Facility (ongoing)

  • Transitional Living Program (30–180 days)

  • Unsure — need guidance

• Brief description of your current situation (Short paragraph field)

Section 3 — Support Needs

Check all that apply:

• Transportation

• Medication assistance

• Case management

• Daily living support

• Mental health stabilization

• Substance use recovery support

• Other needs

(Use a “Checkboxes” field in Squarespace)

Section 4 — Safety & Stability

• Do you feel safe in your current environment?

  • Yes

  • No

  • Unsure

• Any immediate concerns we should know about? (Short paragraph field)

Section 5 — Referral Information

• Are you being referred by an agency, hospital, or caseworker?

  • Yes

  • No

If yes:

• Referring agency name

• Contact person

• Phone/email

Section 6 — Additional Notes

• Anything else you would like KCQC to know? (Paragraph field)

Section 7 — Consent

• I confirm the information provided is accurate to the best of my knowledge.

  • Yes