GOD’S GRACE INDEPENDENT LIVING

GOD'S GRACE ILF INTAKE FORM

919-482-2297

SECTION 1: BASIC IDENTIFICATION
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Race
Preferred Language
Phone Number (Primary Contact) *
Please enter a valid phone number.
Email Address (Secondary Contact)
Please enter a valid phone number.
SECTION 2: MENTAL HEALTH HISTORY
Have you ever been diagnosed with a mental health condition?

YesNo
If yes please list
Have you ever received therapy, counseling, or psychiatric services?

YesNo
Have you ever been hospitalized for mental health reasons?

YesNo
If yes when?
SECTION 3: MEDICAL & PHYSICAL HEALTH
Do you have any physical disabilities or mobility issues?*

YesNo
Are you able to function fully and live independently without ongoing assistance or support?*

YesNo
Can you read and write independently?

YesNo
Do you use any assistive devices? (e.g., cane, walker, wheelchair)
Are there any specific accommodations you require? (e.g., vision/hearing, religious practices, gender preferences)
Any history of seizures, stroke, or heart problems? If yes please explain
Are you able to manage your own medications?

YesNo
Do you have any medical conditions that weaken your immune system (e.g., HIV, cancer treatment, organ transplant)?*

YesNo
Do you ever experience thoughts of harming yourself or others?

YesNo
SECTION 4: LEGAL & CRIMINAL BACKGROUND

Please note: Your answers to these questions will not automatically disqualify you from housing. They are simply used to help determine the most appropriate placement within our program.
Do you use recreational drugs? if yes what type: *
Date last used?

MonthDayYear
Date
Do you drink Alcohol?*

YesNo
If Yes Frequency
Are you currently on probation or parole?

YesNo
Have you ever been arrested or incarcerated?*

YesNo
Have you lived in a group home, shelter, correctional facility, or other congregate setting?

YesNo
Are you a registered sex offender?

YesNo
SECTION 5: FINANCIAL INFORMATION
Source(s) of Income*

SSISSDIRetirementPrivate PayOther
Monthly Income Amount?*
Do you have a Payee

YesNo
If yes Name of Payee if applicable
Are you currently employed?

YesNo
If employed, How many hours Per week?
Employer's Name
Employer's Address
Employer Phone Number
Pay Frequency*
Next Payment date*

MonthDayYear
Date
When are you planning to move?

ImmediatelyWithin 1-2 weeksOn the 1st of the month
Identification Card*

Cancelof
Proof of income( last pay stub) or awards letter*

Cancelof
Room Rates & Options*

Shared Room with one Roommate (Shared Bathroom Down Hallway) $750/MonthShared Room with one Roommate (Bathroom in Room) $800/MonthPrivate Room with Private Bathroom $1,200/Month (NOT AVAILABLE)
Please note, there is a $200 none refundable one time program fee that will be due to hold your requested room. Rent is due the day of move in and will be prorated if you move in after the 1st of the month. Do you understand and agree?*

YesNo
By submitting this application you certify that the information provided is true and complete to the best of your knowledge. You understand that God's Grace ILF is a drug- and alcohol- free environment and that all residents must follow the program rules and policies to remain in the program.

YesNo
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