INTAKE FORM

Name*

First NameLast Name

DATE OF BIRTH?*

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

What best describes your current living situation?*

What is your email?*

Do you require assistance with activities of daily living?*

Gender?*

Are you currently homeless?*

Have you bee diagnosed or experienced any mental health related challenges?*

If yes ... briefly explain diagnosis

Do you have any physical health conditions we should be aware of?*

If yes...briefly describe

Do you smoke?*

Do you drink?*

Can you afford a minimum of $750 per month?*

Do you have a stable source of income?*

What is your income source and how much do you receive monthly?*

Have you ever experienced shared living?*

Are you open to a shared room?*

Are you currently or have been previously incarcerated?*

Are you a registered or non registered sex offender?*

Do you have children?*

Do you have reliable transportation?

Do you have a pet?*

Do we have permission to call you?*

Do you understand that this is a housing program and that you are not applying for a lease?*

Do you have a case manager?*

Please provide caseworker information...

Do you understand that in order to be accepted - you must agree and follow the program rules?*

What is your anticipated move in date?*

How did you hear about us?