Shared Living Intake Questionnaire

Shared Living Intake Questionnaire

Complete form to join our waitlist:
Today's Date

MonthDayYear
Date
Applicant's Name

First NameMiddle NameLast Name
Applicant's Email
example@example.com
Applicant's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
Applicant's Date of Birth

MonthDayYear
Date
Applicant's Current Age
Does applicant possess a current State ID or Driver's License?
Does applicant possess a Social Security Card or copy of card?
Last 4 Digits of Social Security Number
Applicant's Gender At Birth
Gender Applicant Currently Identifies As
Applicant's Race

Other
Applicant's Ethnicity
Is English application's first language?
If answered "No" what is applicant's first language?
Applicant's Emergency Contact

First NameLast Name
Emergency Contact Relationship
Parent, Sibling, Relative, Friend, etc
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who is completing this form?
Representative/Agent Name

First NameLast Name
Representative/Agent Organization (ex: United Way, VA, Facility, etc)
Representative/Agent Email
example@example.com
Representative/Agent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
When does the applicant need to be placed?

MonthDayYear
Date
Applicant's Current Living Situation
Applicant's Current Location Name
(If applicable list business/facility name)
Applicant's Current Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does applicant understand this is a shared living home?
Has applicant lived in shared housing before?
Does applicant agree to sharing a room with at least one (1) other individual?
Is the applicant willing to follow strict house rules? ( No guests, no drugs, no alcohol, no pets, clean space, curfew, etc.)
Does applicant understand this a month-to-month housing program and fees must be paid on time to maintain their housing?
Does applicant vapor or smoke?
Program homes are non-smoking with no exceptions. Applicant is allowed to smoke/vape outside in the designated areas. Does applicant understand our program does not allow smoking/vaping inside our homes?
How long would the applicant want to be apart of our housing program?
Is applicant an US Military Veteran?
How will applicant pay for housing?

Other
How much income does applicant receive monthly? (If none type "NONE")
Is applicant currently employed?
Employer Name
Applicant's primary mode of transportation?
Is applicant able to pay a monthly program base fee of $750 plus a small program entry fee? (Actual program fee amount is assessed individually)
Does applicant have any allergies, medical conditions, or anything we should be aware of?
If "Yes", please explain
Does the applicant suffer from mental illness?
If answered "Yes", list mental illness diagnoses
Do applicant currently take any medications?
If answered "Yes", list medications.
Is applicant disabled?
If answered "Yes" list disability(s)
Does applicant require an accessible living environment?
If answered "Yes" please explain
Is applicant able to preform ADLs (Activities of Daily Living) unassisted?
Does applicant have an animal that will be living with them?
If "Yes" please specify the category of the animal. (Documentation is required and will be verified)
If "Yes" list type and description of animal.
(ex: cat, dog, bird, weight, breed, etc)
Will applicant having children living with them?
Is applicant an ex-offender? (Answering "Yes" does not automatically disqualify applicant from the housing program)
If "Yes", when, and what were applicant's charge(s)?
Does applicant have any outstanding warrants or pending criminal charges? (Answering "Yes" does not automatically disqualify applicant from the housing program)
If "Yes" list the estimated date of the warrant/pending charges and the nature of the warrant/charges
Is applicant currently on Probation or Parole?
Has applicant been convicted as a Sex Offender? (The answer to this question does not automatically disqualify them from the housing program)
Does applicant need help with recovering from Opioid(s) and/or other drugs and alcohol?
Does applicant receive support from a case/social worker, family member, or program?
Does applicant agree to an in-person assessment of ADLs (Activities of Daily Living) prior to being accepted into the housing program?
Please select any assistance applicant may need from the choices below:
How did you hear about us?
If you were referred please list person's and/or organization's name
Anything you would like us to know?
"By clicking submit I and/or my representative/agent understand that if I and/or my representative/agent have deliberately given any false information or have withheld any information regarding any situation, I will be immediately dismissed from the housing program and the no refund policy applies". Program rules are strictly enforced.
Should be Empty: