PA'AR CREATIONS
Pa'ar Creations Independent Living Pre-Screening Questionnaire
Basic Information
1. Name
*
First Name
Last Name
2. Date of Birth
*
-
Month
-
Day
Year
Date
3. Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
4. Email (if available)
example@example.com
5. Where were you referred from? (Agency, case manager, family member, self, etc)
*
Income and Benefits
Are you employeed?
*
Yes
No
7. Do you have a steady source of income?
*
Yes
No
8. Whats your main source of income?
*
SSI
SSDI
VA
Other
9. What is your estimated monthly income? (Proof may be requested in person or electronically
*
10. Do you receive Food Stamps / EBT (SNAP benefits)?
*
Yes
No
11. Do you have a working phone we can use to contact you?
*
Yes
No
12. Are you able to live independently without daily assistance?
*
Yes
No
13. Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc?)
*
Yes
No
If yes please explain
14. Are you currently taking any prescribed medications?
*
Yes
No
If YES List medications
15. Do you have any difficulty accessing your medications (cost, transportation, insurance?)
*
Yes
No
If yes please explain
16. What type of room are you looking for? Private Room, Shared Room, or
*
Shared Room
Private
No Preference
17 When do you need housing? Select move in date
*
/
Month
/
Day
Year
Date
18. Do you have any physical disabilities or mobility concerns?
*
Yes
No
If yes please explain
19. Have you ever been evicted from a previous residence?
*
Yes
No
20. Have you ever been convicted of a felony?
*
Yes
No
21. Are you a registered sex offender?
*
Yes
No
Lifestyle & House Rules
22. Are you willing to follow house rules (no drugs, no unapproved guests, quiet hours, No uncleanliness, etc?
*
Yes
No
23. Do you smoke?
*
Yes
No
24. Do you have any pets?
*
Yes
No
25. Why are you seeking housing at this time?
*
26. Is there anything else you would you like us to know?
Submit
Should be Empty: