Resident Screening & Intake Form

Resident Screening & Intake Form
Section 1: Applicant Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender*

MaleFemaleNot willing to disclose
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Do you have a valid ID/Driver's License?*

YesNo
Do you have a copy of your birth certificate?*

YesNo
Do you have a copy of your Social Security Card?*

YesNo
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.
Section 2: Current Living Situation
Current Living Situation*

HomelessTransitional HousingJail/Prison ReleaseHospital/RehabSeniorOther
Describe "other" living situation
Section 3: Program Fit
What brings you to Nora's Den? (Check all that apply)*

VeteranSenior (65+)Returning citizenExperiencing housing insecurityDomestic violence survivorOther
Describe "other" here
Are you working with any agencies, caseworker, probation officer or programs?*

Yes (if yes, please give agency name and contact information below)No
Add Agency name and contact information here
Do you have a primary source of income or receiving public benefits?*

VA Disability CompensationVA PensionSocial Security (SSI or SSDI)Pension or Retirement Savings (401k, IRA, etc...)Employment IncomeFamily SupportOther
Describe "Other" source of income here
Employment Status*

Full TimePart-TimePer diemUnemployed
Are you currently on probation, parole, or under court-ordered supervision?*

Yes (Explain below)No
Explain "Yes" here
Are you currently able to live in a drug/alcohol-free, shared housing environment?*

YesNo
Due to legal housing restrictions in some areas, we must ask: Are you currently on any sex offender registry?*

YesNoPrefer not to answer (we may follow up for clarification depending on location)
Are you willing to undergo a background check?

YesNo
Section 4: Health & Support Needs
Do you have any physical disabilities or accessibility needs?*

YesNo
Do you require medical care or medication management?*

YesNo
Are you receiving mental health or substance abuse support?*

YesNo
Section 5: Urgency & Preference
Room preference*

Private room (extremely limited at a higher cost)Shared roomNo preference - first available
How soon do you need placement?*

Within 48 hoursWithin 7 daysJust exploring
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