Official Client Intake • Section 3

Client Sign-Up & Housing Compliance Agreement

To be completed by the client during intake. This application initiates your enrollment, clinical evaluation review, and immediate housing placement process.

Safe, Quality Housing & Partnership

Your earned success starts here • Supportive Reintegration Network

Critical Notice to Applicant: The Golden Rule of Housing

Housing provided by Easy Living Concierge Group is an earned privilege rooted in personal accountability. We partner with you by providing safe, furnished, high-quality residential accommodations so you can succeed. However, you must actively comply with all designated mental, physical, and substance outpatient sessions, life-skills classes, and house regulations. Non-attendance or leaving without authorization leads to immediate termination of housing.

1

Personal Demographics

Legal identification, contact details, and designated emergency notification.

Full Legal Name *

Date of Birth *

Social Security Number (SSN)

Enter all 9 digits. Formats automatically (000-00-0000).

Phone Number *

Email Address

Current Living / Mailing Address

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship

2

Housing Needs & Placement Preferences

Preference for housing accommodation tier (subject to program availability and clinical assessment).

Housing Preference

1-bedroom units are prioritized according to family custody situation and tier progression. Fully furnished private rooms with shared community amenities are available to all enrolled individuals.

3

Income, Insurance & Background History

Collected upfront to establish sliding-scale qualification, Medicaid support, and lease transition roadmaps.

Employment Status

Estimated Monthly Income ($ USD)

$

Insurance Provider / Medicaid MCO

Insurance Policy / Member ID

Employment & Vocational History

How Did You Hear About Easy Living Concierge Group?

Additional Clinical or Housing Placement Notes

4

Document Uploads

Upload clear, legible photos or scanned PDFs of your state/federal identification card and Medicaid/insurance card (front and back).

Identification — Front (Driver's License / State ID) *

Click to upload or drag & drop

Attach front of official state ID or passport

Identification — Back

Click to upload or drag & drop

Barcode / back of ID card

Insurance Card — Front (Medicaid / Medicare / Commercial) *

Click to upload or drag & drop

Card showing subscriber & plan number

Insurance Card — Back

Click to upload or drag & drop

Claims address & provider phone lines

5

Applicant Acknowledgement & Compliance Terms

Read each condition carefully. Compliance is mandatory for housing eligibility and tenancy retention.

1

Treatment Compliance

I agree to actively participate in all mental, physical, or substance evaluations and follow-up treatments organized by Easy Living Concierge Group and ABC partners.

2

The Golden Rule of Housing

I understand that my room or apartment is directly tied to my participation. If I stop attending my outpatient or inpatient sessions, leave the program without permission, or refuse evaluations, my housing agreement is terminated immediately.

3

Community & Coping Rules

I commit to attending scheduled life-skills and societal reintegration classes designed to help me rebuild independence and sustainable habits.

4

Property & Safety Regulations

I agree to keep my living space clean, respect my neighbors, adhere to the program curfew (10:00 PM), and strictly honor the zero-tolerance policy regarding illicit substances, alcohol, weapons, and unauthorized overnight visitors.

Applicant Legal Signature (Type Full Legal Name) *

By typing your name, you execute a legally binding electronic signature.

Intake Officer Name / Liaison (If Assisted)

I have read, fully understand, and voluntarily agree to all policies outlined in the Applicant Acknowledgement & Housing Compliance Agreement. I certify that all information submitted herein is true and accurate. I recognize that failure to engage in required clinical evaluations or breach of program conduct directly terminates my housing placement.

Easy Living Concierge Group • Secure Intake Protocol • HIPAA & Maryland 42 CFR compliant

The Easy Living Intake & Housing Pipeline

Standard 4-step workflow connecting intake directly to clinical assessment and rapid residential move-in.

01

1. Referral Received

Referral packet received from case manager, parole officer, clinic, or court liaison.

02

2. Application & Intake

Client completes sign-up, document submission, and housing compliance agreement.

03

3. Clinical Evaluation

Comprehensive medical, mental health, and substance use assessments align individualized care.

04

4. Residential Placement

Clinical profile matched with residential site, key handover, and ongoing support case worker.

Enrollment Packet Initiated

Application Successfully Received

Your intake information and signed housing agreement have been transmitted to the Easy Living Concierge Group clinical intake team.

Application Tracking ID

ELC-2026-0000

Applicant: -

Date & Time: -

Housing Preference: -

Current Status: Referral Received

Easy Living Concierge Group Housing Agreement & Charter

Document Reference: ELCG-COMPLIANCE-REV2026 • Baltimore, MD

ELC

REVISED SEPTEMBER 2026

Residential Living Standards, Treatment Mandate, & Behavioral Charter

Established in coordination with ABC clinical providers to maintain a safe, clean, and sober residential environment.

1 The Golden Rule of Housing & Clinical Attendance

Housing is an incentive and therapeutic stabilization tool directly tied to active engagement with assigned healthcare professionals. Every participant is required to attend 100% of scheduled clinical evaluations, psychiatric appointments, and outpatient group meetings. Unexcused absence or leaving treatment against medical advice (AMA) is considered an immediate voluntary withdrawal from the housing program.

2 Zero-Tolerance Substance, Alcohol & Weapon Policy

To protect the safety and sobriety of all residents:

No alcohol, narcotics, unauthorized prescription drugs, or paraphernalia may be brought on premises.
Random and scheduled toxicology screenings may be administered by clinical staff.
Possession of firearms, bladed weapons, or any hazardous material results in immediate police involvement and permanent discharge.

3 Curfew, Quiet Hours, & Guest Restrictions

A standard curfew of 10:00 PM Sunday through Thursday and 11:00 PM Friday through Saturday is enforced. Exceptions for verifiable employment work shifts must be approved in writing 48 hours in advance by your designated case worker. No unauthorized overnight guests are permitted under any circumstance.

4 Unit Care, Inspections & Community Responsibilities

Residents are expected to maintain clean, hygienic personal rooms and contribute to rotational chores in common kitchens, laundry facilities, and lounges. Routine bi-weekly safety checks are carried out by facility coordinators to verify fire detectors, cleanliness, and maintenance requests.

Ready to begin your transition?

Acknowledge these standards on Section 5 of the intake application to submit your profile.

Client Self-Service

Track Application & Placement Status

Enter your Application Reference ID (e.g. ELC-2026-8801) or applicant full legal name to verify current stage in the intake pipeline.

Staff Intake Queue • Clinical Coordinator Dashboard

Client Applications & Case Management

Ref ID	Client Name	Phone / Contact	Preference	Status	Actions

Confirm Action

Document Preview

Client Sign-Up & Housing Compliance Agreement

Personal Demographics

Housing Needs & Placement Preferences

Income, Insurance & Background History

Document Uploads

Applicant Acknowledgement & Compliance Terms

The Easy Living Intake & Housing Pipeline

1. Referral Received

2. Application & Intake

3. Clinical Evaluation

4. Residential Placement

Application Successfully Received

Easy Living Concierge Group Housing Agreement & Charter

Residential Living Standards, Treatment Mandate, & Behavioral Charter

1 The Golden Rule of Housing & Clinical Attendance

2 Zero-Tolerance Substance, Alcohol & Weapon Policy

3 Curfew, Quiet Hours, & Guest Restrictions

4 Unit Care, Inspections & Community Responsibilities

Ready to begin your transition?

Track Application & Placement Status

No Matching Record Found

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Client Applications & Case Management

Applicant Name