Parole & Probation Referral - Preliminary Intake

This preliminary YES/NO intake form is for probation officers, parole officers, and authorized supervision staff only.

This form is intended to confirm compatibility between court-ordered supervision conditions and independent shared residential housing. HCL Residential Living LLC does not provide supervision, monitoring, reporting, or enforcement of probation or parole conditions.

Completion of this form does not guarantee placement.

Is the individual approximately 60 years of age or older? *

Yes
No

Is the individual a reentry veteran or reentry non-veteran? *

Yes
No

Is the individual seeking independent housing? *

Yes
No

Is the individual able to comply with a standard residential lease? *

Yes
No

Are there no housing-enforced curfews or bed checks? *

Yes
No

Can the individual live independently without supervision? *

Yes
No

Can the individual manage daily living activities independently? *

Yes
No

Can the individual manage medications independently (if applicable)? *

Yes
No

Can the individual attend required appointments independently? *

Yes
No

Does the individual understand no on-site services are provided? *

Yes
No

To your knowledge, does the individual have a stable income or benefit source? *

Yes
No

Is the individual expected to pay rent independently without program assistance? *

Yes
No

Are all reporting requirements handled directly with supervising authority? *

Yes
No

Is all drug or alcohol testing conducted off-site? *

Yes
No

Is all treatment or counseling conducted off-site? *

Yes
No

Is there violent offense-related restrictions? *

Yes
No

Is electronic monitoring tied to the residence or shared spaces? *

Yes
No

Is officer access to the residence required? *

Yes
No

Is housing required to be approved or inspected? *

Yes
No

Are there proximity restrictions affecting the residence? *

Yes
No

Is this referral appropriate for a non-supervised setting? *

Yes
No

Can all supervision conditions be managed independently without requiring monitoring, reporting, enforcement, or documentation by HCL Residential Living? *

Yes
No

Has this residence type (shared, independent, non-supervised housing) been reviewed and approved by the supervising authority? *

Yes
No

Additional Notes (Optional) *

Officer Name *

Agency / Department *

Email Address: *