Intake Form

  • Mitchell's Safe Haven Living
  • Intake Form

Thank you for your interest in our program!

Please fill out this form, as it helps us gather essential information to assess your needs and determine your eligibility for our supportive housing services. This form must be completed in order for us to proceed with placement.

We appreciate your time and look forward to assisting you. Please note that texts and/or calls will be responded to during business hours.

business hours

Monday–Friday: 8:00 AM – 6:00 PM
Saturday & Sunday: 8:00 AM-1:00 PM

By submitting this form, I certify that the information provided is accurate to the best of my knowledge. I understand that Mitchell's Safe Haven will use this information to determine eligibility. I also understand and agree to the following:

  • There are no pets allowed in the program at this time.
  • Mitchell's Safe Haven does not offer in-person tours of the housing facility in order to protect the safety and privacy of current residents.
  • Failure to disclose relevant medical, mental health, or mobility information may result in termination from the program.
  • By signing this form, I agree that I am able to live independently, safely navigate the home, and manage my own personal needs without daily staff assistance.
Alternative options such as photos and video walkthroughs are available upon request.