Parole & Probation Referral - Preliminary Intake

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

The purpose of this form is to determine whether a referral may be compatible with independent, shared housing at HCL Residential Living before a full intake is requested.

Completion of this form does not guarantee placement.

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

Yes
No

Does the individual meet the program eligibility requirement of being an older adult male? *

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 no requirement for housing provider monitoring or reporting? *

Yes
No

Is there violent offense-related restrictions? *

Yes
No

Is on-site supervision or monitoring required? *

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

Can all conditions be managed without housing involvement? *

Yes
No

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

Yes
No

Officer Name *

Agency / Department *

Email Address: *

Additional Notes (Optional) *