Independent Living Housing Intake Form

Independent Living Housing Intake Form

Please complete this form to help us understand your needs and preferences for independent living housing.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleNon-binaryPrefer not to say
Preferred Move-in Date*
Emergency Contact Name and Phone Number*
Medical History and Current Medications
Housing Preferences

Single OccupancyShared RoomPet-FriendlyAccessible HousingOther
If 'Other' Housing Preference, please specify
Special Needs or Accommodations Required

Mobility AssistanceHearing or Visual ImpairmentsDietary RestrictionsMental Health SupportOther
If 'Other' Special Needs, please specify
Financial Information
Income sources (e.g., Social Security, pension)
Insurance coverage
Budget for housing
Functional Abilities
Mobility

Uses caneUses walkerUses wheelchairUses scooterOther
Ability to Perform Activities of Daily Living (ADLs)

BathingDressingToiletingEatingTransferring (bed/chair)
Ability to Perform Instrumental Activities of Daily Living (IADLs)

CookingManaging financesTaking medicationsTransportation
Cognitive Mental Health
Memory issues or diagnoses (e.g., dementia)

Financial Information