Resident Pre-Screening Questionnaire

Resident Pre-Screening

Providing clear & accurate information within the following questionnaire will allow us to make a quick decision and be back with you as soon as possible.
Personal Information
Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
E-mail
example@example.com
How Were You Referred to New Lyfe Homes LLC.?*
Birth Date*

MonthDayYear
Gender*
Are You Currently Pregnant*
IF YES, PLEASE PROVIDE DUE DATE
Due Date

MonthDayYear
Date
Marital Status
Spouse's Name
Current Address and/or Living Arrangement Below*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How Long ?*
Sober Living/Treatment FacilityPrior IncarcerationHomelessHospitalization
Reason for Leaving?*
50 Chars Max.

Legal History
Have you ever been arrested?*
Date

MonthDayYear
Date
If Yes, Provide Charges. If No place N/A*
Have you ever been incarcerated?*
Date

MonthDayYear
Date
If Yes, Provide Conviction. If No Place N/A*
Are You Currently on Probation or Parole?*
If Yes, Provide Probation/Parole Officer's Contact Information
Do You Have Any Pending Legal Matters?*
If Yes, Provide Details & Date(s)

Financial Information
NoneGeneral Assistance/General ReliefCalWorksDisability/Social SecuritySSIOther * Please Explain
*Other Source of Income

Employment
Are you Currently Employed?*
If Yes, Please Provide Details.
Place of Employment, Position, Contact Manager Name & Number, Hrs. Per Wk.
Attending SchoolCurrently Looking for Work*Other
*If Other, Please Explain.

Information on New Lyfe Homes LLC. & Coronavirus (Covid-19)
Notice to All Potential Residents

please be aware that New Lyfe Homes LLC.

will require all incoming residents to submit a negative covid-19 test result within one week before entering home.

As updates on the impact of the Coronavirus continue to be released, we would like to take a moment to inform you of the heightened preventative measures we have put in place at New Lyfe Homes LLC. - these measures have been implemented for the safety of both our residents and staff. All efforts are guided by and in adherence to the recommendations distributed by the Center for Disease Control (CDC).
- CDC updates are consistently monitored to ensure that all guidance followed is based on the latest information released.
- All staff has received infection prevention and control training.
- Thorough, daily disinfection of all office surfaces following each class.
- Patient care supplies such as masks and hand sanitizer are being monitored and utilized
- CDC informational posters are on display to provide important reminders on proper infection prevention procedures
The safety of our residents and our staff is our top priority, and we will remain steadfast in our efforts to reduce any risk associated with Coronavirus (COVID-19).

The CDC has provided a list of easy tips that can help prevent the spread of the Coronavirus:
- Avoid close contact with people who are sick
  Cover your cough or sneeze with a tissue and then immediately dispose of the tissue
- Avoid touching your eyes, nose, and mouth
  Clean and disinfect objects and surfaces that are frequently touched
- Wash your hands often with soap and water for at least 20 seconds
- Stay home when you are sick, except to get medical care
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Resident Pre-Screening

Personal Information

Legal History

Financial Information

Employment

Information on New Lyfe Homes LLC. & Coronavirus (Covid-19)