Independent Living
Shared housing intake form
Name
First Name
Last Name
Date of Birth
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Current Address
Who referred you/Name and Contact
Are you able to live independently without daily assistance?
Yes
No
Do you currently receive assistance with daily activities? (cleaning,meal prep,hygiene, etc.)
Yes
No
Have you been medically diagnosed with any mental health conditions?
yes
No
If yes to the above question, what is that mental condition and what behavioral activities do you have?
Are you taking any prescribed medications?
Yes
No
Do you have a steady source of income?
Yes
No
What is your estimated monthly income? ( Proof of income will be requested)
Do you receive Food Stamps/EBT Benefits
Yes
No
Do you have a support system, if so who?
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
Yes
No
What type of room are you interested in?
Shared Room
Private Room (Rates may differ)
Do you have any physical disabilities or mobility concerns?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If you answered yes to the question above, what does the charge regards to?
Are you a registered sex offender?
Yes
No
Are you a smoker?
Yes
No
Do you understand and agree that you are applying for a program that is a month-to-month basis due to you following the policies of the program. Upon reviewing your intake, we will run a background check for all major criminal charges that doesn't align with our program.
Yes
Signature
Continue
Continue
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