Supportive Living Intake Form

Supportive Living Intake Form

Welcome to Just Us Community Homes Shared Living. We're an Independent living Community.
Clients

First NameLast Name
Gender
What best describe you?

VeteranElderlyAdult needing affordable housing during a rough timeOther
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact

NamePhone Number
Are you comfortable living in an environment that emphasizes structure and adherence to clearly defined house rules?

YesNo
Rooming Arrangment

Shared RoomPrivate Room
How will client pay?

SSISSDIRetirementVoucherOrganization Funding
How much income do you receive monthly? if none type NONE
Where do you currently live?
Do you have any Identification? Please Upload if possible
Cancelof
Do you smoke?

YesNo
Race

CaucasianAfrican AmericanHispanicAsianAmerican Indian/Native AmericanIslanderOther
Do you have mental health diagnosis?

YesNo
If yes, list diagnosed mental conditions
Do you take medication?

YesNo
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*

YesNoWithin 1000ft restrictionWithout 100ft restriction
Are you Currently on Probation or Parole?

YesNo
Do you require assistance with activities of daily living? (bathing, dressing, ambulating, etc.)

YesNo
We do not provide medical care or assistance with activites of daily living. All residents must be functionally independent.
Do you require assistance with any of the following?

Job PlacementApplying for SNAP benefitsApplying for SSI/SSDIApply for VA benefitsApply for Clothing DonationsMedication pick up and reminders ( no administration)Health Insurance EnrollmentCell phone/Tablet AssistanceGroup TherapyLife Skills/ Recovery Groups
Does client require a Handicap Accessible living environment?

YesNo
How soon are you looking to move in?
Should be Empty: