This sample intake form for compatibility is designed to address both the immediate needs and the long-term readiness of potential participants for the Human Rescue Albuquerque rural transition program.
Given the unique nature of land-based living, this form prioritizes safety, physical capability, and a commitment to the “Lease-to-Steward” model.
Human Rescue Albuquerque: Participant Intake & Compatibility Form
Section 1: Basic Information
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Full Name: ________________________________________________
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Date of Birth: ____ / ____ / ________
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Current Location/Contact Method: ___________________________
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Emergency Contact: _________________________________________
Section 2: Compatibility Screening
To be eligible for the pilot program, applicants must meet the following baseline criteria:
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Housing Status: Are you currently experiencing housing instability or homelessness?
[ ] Yes [ ] No
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Environment Preference: Are you willing and able to relocate to a rural, off-grid setting?
[ ] Yes [ ] No
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Physical Capability: The program involves light construction (shelter assembly) and gardening. Do you have any physical limitations we should be aware of to provide proper accommodations?
(Please specify): ________________________________________________
Section 3: The 5 Pillars Assessment
This section helps us customize your “Rescue Kit.”
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Shelter: Do you currently have a tent or mobile structure, or do you require a tiny-home shell?
[ ] Have my own [ ] Need shelter provided
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Sanitation: Are you comfortable utilizing and maintaining a composting toilet system?
[ ] Yes [ ] No [ ] Need training
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Food Security: Do you have any specific dietary restrictions or medical needs regarding the 6-month food stipend?
(Please specify): ________________________________________________
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Stewardship: Do you have any previous experience with gardening, farming, or basic tool repair?
[ ] None [ ] Beginner [ ] Experienced
Section 4: Goals & Readiness
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Why are you interested in a rural transition rather than urban housing?
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What is your primary goal for the next 6 months? [ ] Job placement [ ] Mental health recovery [ ] Learning agricultural skills [ ] Other: ________
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Are you willing to participate in a “Community Fee” ($50–$100/mo) once you have achieved financial stability? [ ] Yes [ ] No
Section 5: Safety & Community
Human Rescue Albuquerque is a community-based environment.
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Do you have any active legal restrictions that would prevent you from living in a communal rural setting? [ ] Yes [ ] No
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Will you be accompanied by a pet or service animal? (Note: All animals must be registered and compatible with a farm environment.) [ ] Yes (Species/Breed: ___________) [ ] No
Applicant Acknowledgment
I understand that HumanRescue.org is an off-grid program and that my participation requires a commitment to land stewardship and community safety.
Signature: _________________________________ Date: _______________
