Client Intake Form – Graceful Services Foundation Inc.










    Are you comfortable living in a shared housing environment?*

    Please note: This program offers shared living only. Private rooms may be available starting at $900/per month.




    Do you have a history of mental illness or currently live with a mental health condition?*

    If yes, how would you describe the severity of your condition?




    Do you have a disability or require any accommodations?*


    Are you an ex-offender?*


    This information is used to better understand your background and determine how we can best support your placement. Your response will not automatically disqualify you.

    Have you ever been convicted as a sex offender?*

    (Answering “Yes” will not disqualify you.)


    Do you consume tobacco?*

    Do you consume alcohol?*

    If approved, are you able to pay a $200 non-refundable deposit?*


    Financial Readiness – If approved, will you be able to pay the $50 bed hold fee?*


    Emergency Contact






    Terms and Conditions

    By submitting this form, you agree to:

    • Review process does not guarantee placement.

    • We may follow up for more info.

    • All info must be accurate.

    • Your data is kept confidential.

    • Typical response time is 5–10 business days.

    • You must follow all house rules if accepted.

    • This is not a landlord-tenant relationship.



    Electronic Signature Consent: By typing your name above, you confirm this acts as your legal electronic signature and certify that all provided information is true.