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Our goal is to help residents move from uncertainty to stability and from stability to independence.

Date of Intake:

Referral Agency/ Name of Referrer

First Name

Last Name

Date of birth

Age:

Social Security Number (Last 4 digits):

Phone *

Email *

Gender:

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

Referring Contact Name:

Brief Summary of Situation / Reason for Housing Need

Medical & Mental Health History (List Below)

Substance use history (if any):

Alcohol

Drugs

None

Legal Background

Are you currently on parole or probation? (List PO Name/Phone Number)

Are you a registered sex offender?

Income Information

Do you have a source of income?

Source of Income

Monthly Income Amount (if any): $

Housing Preferences or Needs

Any disabilities or accommodations needed?

Please explain:

Preferred Room Type:

Shared Room

Private Room (if available)

Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.

You must be able to manage your own:

Personal hygiene and grooming
Meal preparation and eating
Medication (unless managed by an outside provider)
Mobility and transportation arrangements
Housekeeping and laundry
Daily living responsibilities

If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?

Do you currently have or need a home health care provider or outside support service?

Agency Name (if applicable):

Program Agreement Preview

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.

I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.

I acknowledge that violating rules may result in a strike or dismissal from the program.

Applicant Declaration

I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.

Signature

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Phone: 727-463-8520

Email: [email protected]

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Whether you’re seeking housing or looking to partner, Springs is here to support the journey.

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