Pathway Restoration Intake Form
We be happy to have you!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Are you fully independent and able to manage daily tasks on your own?
*
Yes
No
Preferred Method of Contact
Text
Email
Call
If no, briefly explain what support you may need.
Do you currently have a source of income?
*
Yes
No
How do you receive income? (To be verified)
*
SSI
SSDI
Pension
Self employment
Job
Other
Upon acceptance there is a non-refundable community fee ($150-$300) due in addition to your monthly membership fee. May be prorated based on join date.
*
I understand
Are you currently taking any medications that may impact shared living or that we should be aware of for safety reasons
*
Yes
No
If you’re comfortable sharing, please list the medication(s) and anything we should be aware of (e.g., storage needs, side effects that may affect shared spaces.
Is there anything you'd like us or your future housemates to know?
Do you have any allergies, habits, or routines to mention?
Submit
Should be Empty: