Intake Form

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 NameLast Name
Gender
Date of Birth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you currently have housing?
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have valid ID/Documents?
Do you smoke?
Do you use alcohol?
Do you have a history of alcohol abuse/addiction?
Do you use substance?
Do you have a history of substance abuse/addiction?
Do you have a support system?
Do you have a pet?
REQUIREMENTS
Are you willing to follow house rules?
Are you high functioning and able to live independently without requiring assistance with daily task?
Are you willing to be housed in a shared living space (shared room, kitchen bathroom, common area}?
Are you willing to pay a deposit prior to being housed?
Are you willing to pay a non-refundable community fee prior to being housed?
FINANCES
Are you employed?
If not, what is your income source?
How often do you receive your income?
What specific day/days of the month do you receive your income?
TRANSPORTATION
Do you have reliable transportation?
Do you drive?
If so, will you be bringing a vehicle?
Please provide vehicle color, year, make and model.
MEDICAL
Do you have a mental health diagnosis?
If so, what is the diagnosis?
Do you take any medications?
If so, list all medications that you take.
Are you mobile (not requiring a wheelchair, cane etc.)?
Are you incontinent?
CRIMINAL HISTORY

Answers to the following questions does not disqualify you from our program.
Have you ever been convicted of a felony?
If so, what was the crime?
Have you been convicted as a sex offender?
Do you have any pending cases?
Are you currently on parole?
Are you currently on probation?
EMERGENCY CONTACT INFORMATION
Relation to Applicant
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
REFERRING AGENCY
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Thank you for applying.

A representative will contact you soon.
Should be Empty:

LIVING PURPOSE

INTAKE FORM

PERSONAL INFORMATION

REQUIREMENTS

FINANCES

TRANSPORTATION

MEDICAL

CRIMINAL HISTORY

EMERGENCY CONTACT INFORMATION

REFERRING AGENCY

Thank you for applying.