Independent Living Pre-Screening Questions
1 Full Name
*
2 Date of Birth
*
/
Month
/
Day
Year
Date
3. Phone Number
*
4 Email Address if available
*
example@example.com
5 Current Address
*
6 Where were you referred from Agency case manager family member self etc
*
7. Do you have a steady source of income?
*
Yes
No
8. What is your source of income?
*
SSI
SSDI
Employment
Hourly pat rate
*
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*
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9. What is your estimated monthly income? (We may ask for confirmation - proof can be shown in person or sent electronically Name of employer # of hour per week a question
*
10. Do you receive food stamps?
*
11. Do you have a working phone that we can contact you on?
*
12. Are you able to live independently without daily assistance?
*
13. Do you currently recieve help with daily activities?
*
14. Are you currently taking prescribed medications?
*
Yes
No
15. Do you have difficulty accessing your medications? (cost, transportation,insurance)?
*
Yes
No
16. When do you need housing Move-in date
*
/
Month
/
Day
Year
Date
17. Do you any have any physical disabilities or mobility concerns?
*
Yes
No
18.Have you ever been convicted of a felony?
*
Yes
No
If so, details of year and crime.
19. Are you a registered sex offender?
*
Yes
No
20. Are you willing to follow the house rules?( No drugs, no alcohol, no unapproved guest, quiet hours, cleanliness, ect.)
*
Yes
No
21. Why are you seeking housing at this time
*
22. What are your goals within the next year
*
23. What are 3 things that make you different from others?
*
24. What are some of your hobbies?
*
25. What type of room are you looking for?
*
Private
Shared
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