Personal Information

Do you have a current ID?*

YesNo

Street Address

Emergency Contact

Relationship

Background Information

Are you currently homeless?*

YesNo

If yes, please explain

Previous Address

Do you have current insurance?*

YesNo

If yes, insurance provider

Any past or current charges or felonies?*

YesNo

If yes, please explain

Are you on probation or parole?*

YesNo

Current Income Source

Any health conditions we should be aware of?

Do you have a vehicle?*

YesNo

Medical Information

Do you have allergies to food, medication, prescriptions, or over-the-counter medicine?*

YesNo

If yes, please list allergies

List below medications you are currently taking and prescribing physician

I agree these medications are prescribed to me by a physician and I will not share medications with others.

Program Needs

What services are you seeking?

HousingCase ManagementEmployment SupportRecovery SupportTransportation HelpOther

Please describe your immediate needs

Additional information

Mandated Non-Refundable Program Fee and Savings Agreement

While you are a client at the Burfoot House program, your goal is to become financially stable so that you can move/transition into a place of your own. You will work with your assigned mentor to create and follow a budget and savings plan.

Non-Refundable Mandated Program Fee of $500.00 and Savings Policy Requirements:

1. Each client is required to pay a non-refundable program fee of $500 each month by the 5th of the month.

2. Fifty percent (50%) of income will be saved for transition to permanent housing unless a reviewed budget is approved by leadership.

3. All income received must be reported to your Mentor. Pay stubs or earnings statements must be provided after each paycheck.

I acknowledge and agree to the Mandated Non-Refundable Program Fee and Savings Agreement.*

Non-Disclosure Agreement

As part of the Burfoot House program, I may have access to confidential client and volunteer information in written, electronic, and verbal form.

I understand this information is for official use only and may not be disclosed without official authorization or a legitimate need to know.

I understand unauthorized disclosure may result in administrative action, including removal from the Burfoot House program.

I acknowledge and agree to the Non-Disclosure Agreement terms.*

Acknowledgement Form

I agree that I will open a Dollar Bank savings account upon acceptance into the program and before entering Burfoot House.*

I acknowledge I have read and agree to adhere to all rules, policies, and procedures in The Burfoot House Client Handbook.*

I understand there is video and audio monitoring at the Burfoot House and van to promote and ensure safety.*

I agree that I will not take pictures or audio recordings at the Burfoot House for client privacy.*

I give permission to Burfoot House staff and leadership to use photographs taken during my residency for program promotion.*

Consent + Signature

I acknowledge that I have read and understood the Client Privacy Statement and consent to the collection and use of my personal information.*