WELCOME
TO
VOAKS HOMES

Resident Intake Form

Today's date and Time
Client's Information
Address
Date of Birth
Ethnicity
Any history of domestic violence?
Are you at the risk of homelessness?
Do you have a long duration disability?
Do you have any current legal issues?
Do you have a notable physical condition?
Marital Status
Are you currently on parole?
Current Diagnosis
Specialized care requirements
Payment Method
Do you have a Payee?

What is 7+4?

Residential State Supplement
(RSS) Forms

Download and complete the RSS application using the buttons below. Send all completed applications to:

RSS@mha.ohio.gov or faxed to 614-485-9747

Download RSS Program Application
Download RSS-ROI Authorization
Download RSS- ODM Enrollment Referral

>> View Details at here mha.ohio.gov website <<