INTAKE FORM

PARTICIPANT SCREENING QUESTIONNAIRE
Date

MonthDayYear
Date
Participate Name
Phone Number
Referred By
Q1: Do you have a steady source of income?

If yes, please check all that apply:
SSI / SSDI
VA Benefits
Employment Income
Family Support
Community Funding Program
Other
Q2: Are you able to pay monthly program fees (ranging from $650 to $900)?
Q3 Do you have a mental health diagnosis
If yes please specify
Q4: Are you currently taking any prescribed medications related to your mental health?

N/A No Yes
Q5: Are you able to live independently without assistance with daily activities (bathing, dressing, cooking, medications, etc?
Yes
No
Q6: Do you understand that this program does not provide staff for daily assistance?
Yes
Q7: Have you ever been convicted of a sex offense?
Yes
*Note: We do not conduct background checks except to verify no active sex offender status.*
Q8: Do you have any accessibility needs (e.g., wheelchair access, quiet environment)?
Yes
If yes please explain
Q9: What are your current living circumstances?
Shelter

ShelterHospital dischargeLiving with friends/FamilyOther
Street Homeless
Other
Q10 What is your preferred movein date

MonthDayYear
Date
I confirm that the information provided is true to the best of my knowledge. I understand that Heal and Build Independent Living LLC is an independent living program and does not offer personal care
Applicant Signature

Clear
Date

MonthDayYear
Date
Staff Reviewer
Date

MonthDayYear
Date
Should be Empty:

PARTICIPANT SCREENING QUESTIONNAIRE