LIVING PURPOSE
Independent Living Housing Program
INTAKE FORM
Please fill out the following information to apply for our independent living housing program and to be placed on the wait list.
PERSONAL INFORMATION
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
Phone Number
Please enter a valid phone number.
Email
example@example.com
Do you currently have housing?
Yes
No
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have valid ID/Documents?
NYS issued photo ID
Social Security Card
Birth Certificate
Proof of Income
Do you smoke?
Yes
No
Do you use alcohol?
Yes
No
Do you have a history of alcohol abuse/addiction?
Yes
No
Do you use substance?
Yes
No
Do you have a history of substance abuse/addiction?
Yes
No
Do you have a support system?
Yes
No
Do you have a pet?
Yes
No
REQUIREMENTS
Are you willing to follow house rules?
Yes
No
Are you high functioning and able to live independently without requiring assistance with daily task?
Yes
No
Are you willing to be housed in a shared living space (shared room, kitchen bathroom, common area}?
Yes
No
Are you willing to pay a deposit prior to being housed?
Yes
No
Are you willing to pay a non-refundable community fee prior to being housed?
Yes
No
FINANCES
Are you employed?
Yes
No
If not, what is your income source?
How often do you receive your income?
Weekly
Biweekly
Monthly
What specific day/days of the month do you receive your income?
TRANSPORTATION
Do you have reliable transportation?
Yes
No
Do you drive?
Yes
No
If so, will you be bringing a vehicle?
Yes
No
Please provide vehicle color, year, make and model.
MEDICAL
Do you have a mental health diagnosis?
Yes
No
If so, what is the diagnosis?
Do you take any medications?
Yes
No
If so, list all medications that you take.
Are you mobile (not requiring a wheelchair, cane etc.)?
Yes
No
Are you incontinent?
Yes
No
CRIMINAL HISTORY
Answers to the following questions does not disqualify you from our program.
Have you ever been convicted of a felony?
Yes
No
If so, what was the crime?
Have you been convicted as a sex offender?
Yes
No
Do you have any pending cases?
Yes
No
Are you currently on parole?
Yes
No
Are you currently on probation?
Yes
No
EMERGENCY CONTACT INFORMATION
Relation to Applicant
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
REFERRING AGENCY
Agency Name
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Thank you for applying.
A representative will contact you soon.
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