CLIENT INTAKE FORM

FOR REFERRAL PARTNERS

Welcome to the A.C.T.S Of Love Global

Client Intake Form.

Please complete this form with accurate and current information so our team can review your intake and determine the next steps for placement.

This form is intended for the client or applicant seeking sober living, transitional housing, supportive housing placement, or related support services. The information you provide will help our team prepare for the next part of the process, including placement review and any required program agreements.

You will be asked to provide personal information, emergency contact details, recovery and treatment information, medication information, payment or insurance details, and any available documents.

If you do not have all required documents right now, you may still complete the form. Missing documents can be submitted later if needed.

After your intake has been reviewed and approved, our team may send you the Transitional Housing Program & Occupancy Agreement for completion and signature.

Important Notice

Please do not submit this form more than once for the same client.

If you need to update information or send additional documents after submitting the form, please contact our team instead of completing a new intake form.

Client Information

Emergency Contact Information

*You can upload up to 10 documents or photos for the supporting documents.

Current Living Situation

Requested Move-in Time Frame

Recovery / Treatment Information

*You can upload up to 10 documents or photos for the supporting documents.

Placement Support Requested

Please select one option only

Sober Living

Transitional Living

Supportive Housing Placement

Veteran Placement Support

Elderly Supportive Placement

Domestic Violence Survivor Support

Reentry / Justice-Involved Placement

Substance Use History

Mental Health / Medical Information

*You can upload up to 10 documents or photos for the supporting documents.

Court / Probation Information

*You can upload up to 10 documents or photos for the supporting documents.

Payment Information

Health Insurance

*You can upload up to 10 documents or photos for the supporting documents.

Additional Notes

Important Program Notice

This submission collects information needed for review and possible placement with A.C.T.S of Love Global LLC. Submission does not guarantee admission, approval, or housing placement. All submissions are subject to review, eligibility, availability, funding/payment approval, and final approval by A.C.T.S of Love Global LLC.

If accepted, the participant will be required to review and sign the Transitional Housing Program & Occupancy Agreement and the House Rules & Program Policies Acknowledgment before admission or move-in.

Client Authorization