Independent Living Community Intake Form

Independent Living Community Intake Form

Please fill out the following form to help us understand your needs and preferences for independent living.
Date

MonthDayYear
Date
Full Name*

First NameLast Name
Gender

MaleFemaleNon-BinaryPrefer not to say
Date of Birth*

MonthDayYear
Date
Age
Last 4 digits of Social Security
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Referral Source (If Applicable)

SelfAgency:Parole/ProbationHospital or Treatment CenterFamily/Friend
Referring Contact Name:
Include Phone/Email
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Current Living Situation

HomelessCouchsurfing / Staying with othersTransitional HousingJail / Prison ReleaseHospital / Rehab
Please tell us about your current living situation and any specific needs or preferences and reason for housing.
Do you require assistance with daily activities? (If Yes, Please explain)
Medical & Mental Health History/Diagnosis (List Below)
Substance Abuse History

AlcoholDrungsNone
Are you currently on parole or probation?

YesNo
If yes, please explain below.
Are you a registered sex offender?
Do You have a Source of Income?

YesNoSSI, SSDI,Other
Other Source of income:
Monthly Income Amount (if any):
Indepentend Livinng & Functionality Acknowledgment

Our Program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home or an assisted living facility. We do not provide medical care, personal care or supervision.

You must be able to manage your own:
- Personal Hygiene and grooming
- Meal preparations and eating
- Medication (unless managed by an outside provider)
- Mobility and transpostaion arragnements
- Housekeeping and Laundry
- Daily living responsibilities
If you require medical or personal care services, they must be provided by a licensed outside agenccy or caregiver, arranged and paid for separately.
Do you currently have or need a home health provider or outside support services? (If Yes, Please Explain and list Agency name if applicable.)
I understand and agree that this program provides housing only. I understand that I will have a roommate unless I pay for a single room. I will be responsible for my personal care, medical needs and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.
Signature

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Program Agreement Preview
I understand that if accepted, I must follow all house rules, expectations and participate in case management or program-related check-ins/meetings.

I acknowledge that violating rules may result in violation or dismissal from the program.
Signature

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Applicant Declaration
I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement and my application will be reviewed by staff.

Participant Signature

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Date

MonthDayYear
Date
Staff Name

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Date

MonthDayYear
Date
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