Serenity Haven Housing, LLC Intake Form

Serenity Haven Housing, LLC Intake Form

Please complete this form to provide essential information for new residents. Your responses will help ensure a safe and comfortable experience.
Who is completing this form?*

The ResidentA Representative (Family Member, Guardian, etc.)
Resident's Full Name*

First NameLast Name
Resident's Date of Birth*

MonthDayYear
Date
Resident's Phone Number*
Please enter a valid phone number.
Resident's Email Address*
example@example.com
Resident's Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Representative's Full Name (if applicable)

First NameLast Name
Representative's Phone Number (if applicable)
Please enter a valid phone number.
Representative's Email Address (if applicable)
example@example.com
Primary Emergency Contact Name*

First NameLast Name
Relationship to Resident (Primary Emergency Contact)*

Spouse/PartnerParentChildSiblingFriendOther
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email (optional)
example@example.com
Secondary Emergency Contact Name (optional)

First NameLast Name
Relationship to Resident (Secondary Emergency Contact)

Spouse/PartnerParentChildSiblingFriendOther
Secondary Emergency Contact Phone Number (optional)
Please enter a valid phone number.
Please list any current medical conditions or diagnoses.
Please list any allergies (medications, foods, etc.).
Please list any medications currently taken.
Does the resident have any special needs or require accommodations?

Mobility assistanceDietary restrictionsVision/hearing assistanceOther (please specify)
If you selected any special needs or accommodations, please provide details.
Additional information or comments (optional)
Type of Income Received*
Select the type of income received
Amount of Income Received*
Select the source of income received
Payment Method*
Select your preferred payment method
Should be Empty: