Resident Screening & Intake Form

Resident Screening & Intake Form
Section 1: Applicant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Do you have a valid ID/Driver's License?
Do you have a copy of your birth certificate?
Do you have a copy of your Social Security Card?
Emergency Contact
Emergency Contact 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.
Section 2: Current Living Situation
Current Living Situation

Other
Describe "other" living situation
Section 3: Program Fit
What brings you to Nora's Den? (Check all that apply)

Other
Describe "other" here
Are you working with any agencies, caseworker, probation officer or programs?
Add Agency name and contact information here
Do you have a primary source of income or receiving public benefits?

Other
Describe "Other" source of income here
Employment Status
Are you currently on probation, parole, or under court-ordered supervision?
Explain "Yes" here
Are you currently able to live in a drug/alcohol-free, shared housing environment?
Due to legal housing restrictions in some areas, we must ask: Are you currently on any sex offender registry?
Are you willing to undergo a background check?
Section 4: Health & Support Needs
Do you have any physical disabilities or accessibility needs?
Do you require medical care or medication management?
Are you receiving mental health or substance abuse support?
Section 5: Urgency & Preference
Room preference
How soon do you need placement?
Section 6: Final Notes
Please share anything else you would like us to know
Disclaimer By submitting this form, I certify that the information provided is accurate and truthful. I acknowledge that Nora's Den Co-living Community is an independent living program and NOT a licensed treatment facility or landlord-tenent arrangement.

Certain questions on this form are used solely for program eligibility, placement suitability, and compliance with local housing laws or restrictions. Information regarding legal supervision, criminal history, or registry status will be treated confidentially and evaluated in accordnace with applicable laws and public safety requirements.

Submission of this form does not guarantee placement.
By checking this box, I consent to receive communication from Nora's Den regarding my waitlist status, placement opportunities, program updates, or related services I have requested. Message frequency may vary depending on placement availability or eligibility follow-up. Message and data rates may apply. Reply HELP for assistance or STOP to opt out at any time.
Full Name

First NameLast Name
Should be Empty:

Resident Screening & Intake Form

Section 1: Applicant Information

Emergency Contact

Section 2: Current Living Situation

Section 3: Program Fit

Section 4: Health & Support Needs

Section 5: Urgency & Preference

Section 6: Final Notes