Shared Housing Independent Living Intake Form
Help us help you
Name
First Name
Last Name
Date of Birth
Gender
Current address/Previous address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current living situation (How Long) and (Reason)
Email
example@example.com
Phone Number
Please enter a valid phone number.
May we text the above phone number?
YES
NO
Bedroom preference
Private
Double
Multi Bed
Anticipated Move in Date
Income Source
SSI
SSDI
Private Pay
Employment
Organization
Please upload proof of income if applicable
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Monthly income amount
Please list any mental illness diagnosis or disabilities
Do you require handicap access?
YES
NO
Are you a registered sex offender?
YES
NO
If so, date of offense
Are you currently on probation or parole?
YES
NO
If yes to the above question, what was your charged offense(s) and dates of?
Are you in alcohol or substance abuse recovery?
YES
NO
Do you smoke or drink
SMOKER
DRINKER
BOTH
Do you have a support team (family, friends, spouse, sponsor) and or case management? Please list case manager name and number if applicable
Emergency Contact Name and Number
How did you hear about us (social media, referral, flyer, search engine)?
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