Pre-Screening Assessment

Pre-Screening Assessment

Ensuring Personalized Care and Support for Every Individual
THANK YOU FOR YOUR INTEREST.

This pre-screening questionaire is designed to help us assess the needs and eligibilty of potential residents. By providing accurate information, you assist us in determing if our home is the right fit for the applicant and ensuring we can provide the necessary care and support.

All responses will remain confidential and will be used solely for the purpose of evaluating residency.
1) What is your current living situation?*

At home (with family)Living independentlyHomeless or at risk of homelessnessHospital or rehabilitation centerOther
Reason for leaving: *
2) Are you applying for yourself on behalf of someone else?*

SelfParent/GuardianCaseworkerAgencyOther
3) What type of housing are you seeking?*

Veteran HousingTransitional HousingAssisted LivingSober HousingIndependent LivingOther
4) Within the last 30 days, has applicant lived in a shared housing setting?*

YesNo
If Yes, please indicate details of Where and When:
5) Do you smoke?*

YesNo
Anticipated Move-In Date:*

MonthDayYear
Date
6) What type of housing are you seeking?*

Shared SpacePrivate RoomOpen to either

7) Do you have any of the following conditions or diagnosis? *

	Yes	No
Intellectual or Developmental Disabilities
Mental Health Disorders
Physical Disabilities
Chronic Illness (e.g. diabetes, heart disease, etc)
Substance Abuse History

8) Do you require any of the following services or care? *

	Yes	No
Medication Management
Assistance with activities of daily living (e.g. bathing, dressing)
Mobility assistance (e.g. wheelchair)
24/7 supervision
Behavioral support or counseling
Medical care (e.g. nursing care, therapy)

9) Do you have any known allergies (food, medication, environmental)?*

YesNo
If Yes, please list:
10) Are you currently taking medications?*

YesNo
If Yes, please list medications:
11) Do you have any history of mental health treatment or counseling?*

YesNo
If Yes, please explain:
12) Do you have any history of substance abuse or addiction?*

YesNo
If Yes, are you currently receiving treatment?
13) Have you experienced any behavioral challenges or issues (e.g. aggression, wandering, self-harm?*

YesNo
If Yes, please explain:
14) Are you currently on parole or probation?*

YesNo
15) Do you have any pending court cases?*

YesNo
If Yes, please explain:
16) Do you have any dietary restrictions or special dietary needs?*

YesNo
If Yes, please explain:
17) Do you receive state funded food assistance?*

YesNo
18) Are you currently working with any service agencies (e.g. social workers, case managers)?*

YesNo
If Yes, please provide contact information:
19) Do you receive Medicaid?*

YesNoPending
20) What is your current employment status?*

Employed- Full TimeEmployed- Part TimeUnemployed- Looking for WorkUnemployedOther
21) What is your funding source?*

SSISSDIVoucherPrivate PayRetirementOther
22) Which best describes your monthly income?*

$699 or less$700-$1000$1001-1500$1500+
If other income source, please explain :
Number of minor dependents:*

23) What are your primary reasons for seeking residency in a group home?*

	Check all that apply.
Need assistance with daily living?
Desire a safer or more stable environment?
Need ongoing medical or behavioral support
Seeking greater independence?

24) What goals are you seeking to accomplish while residing in a group home?*

	Check all that apply.
Increased independence
Improved health and well-being
Social and community engagement
Short term stay for rehabilitation or recovery

4) OFFICE USE ONLY (Pre-screening reviewed by; date; notes)?
I certify to the best of my knowledge; this information is accurate. I understand that this is a pre-screening process and additional documentation or assessments may be required.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date*

MonthDayYear
DateHourMinutesAM/PM Option
I certify to the best of my knowledge; this information is accurate. I understand that this is a pre-screening process and additional documentation or assessments may be required.
Should be Empty: