Contact form

<h3 style="text-align:center">Sharon’s House of Care Intake Form</h3>
<p>Thank you for your interest in Sharon’s House of Care. This form helps us get to know you better and understand your needs, so we can provide the right support in a safe and structured environment.</p>

name

Date of Birth

Gender

email

phone

address:full

Emergency Contact

Relationship to You

Phone

What is your current living situation?

Family

Shelter

Transitional Housing

Recovery Facility

Hotel

Recently Released From Incarceration

Hospital

Unhoused

Other

Have you lived in a group/shared home before?

Do you have any pending legal issues or probation requirements? (Yes/No + explain)

Do you take any prescribed medications? (Yes/No + list if comfortable)

Do you have a disability or condition that requires daily support?

Do you have a history of substance use recovery? (Yes/No + optional details)

What are your main goals for moving into Sharon’s House of Care?

What type of support do you feel you need most right now?

Structure

Encouragement

Accountability

Daily Living Support

Do you have a source of income?

SSI/SSDI

Family Support

None

I understand Sharon’s House of Care is a structured, spirit-led shared living environment.