Pre-Check Eligibility Form

Pre-Check Eligibility Form

This form helps determine if RAD Independent Living may be a good fit. Submitting this form does not guarantee placement.
Resident Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Birthdate*

MonthDayYear
Date
Referring Agency
Case Worker

First NameLast Name
Email Address
Phone Number
Please enter a valid phone number.
SECTION 1 – Basic Eligibility *

I am 18+ years or olderI am seeking stable housingI can live independently with light supportI am willing to follow house rulesI am willing to participate in check-ins
I understand this is a structured, shared living environment*

YesNo
Room Option*

Shared RoomPrivate Room
Does this person have a vehicle?

YesNo
SECTION 2 – Housing Readiness*

I do not require 24/7 medical careI do not require a group home settingI do not require emergency shelterI can manage daily living tasks independently
SECTION 3 – Income Do you have a income source?*

YesNo
Payment Source List all that apply*

SSDISSIVA BenefitsPayeeAgencyOther
Monthly budget?*
SECTION 4 – Program Fit*

I am not a registered sex offenderI do not have recent violent felony convictionsI am not actively using substances without treatmentI do not require locked or clinical supervision
SECTION 5 – Support Needs *

Employment assistanceEducation or trainingBudgeting or life skillsCase management coordinationTransitioning from shelter/program
SECTION 6 – Referral Source How did you hear about RAD Supportive Living?*

SelfCase Manager / AgencyShelterTreatment ProgramOther
SECTION 7 – Consent & Acknowledgment*

I certify the information provided is accurateI understand this is a pre-screen, not an applicationI give permission to be contacted by RAD Supportive LivingI understand submission does not guarantee acceptance
Today's Date*

MonthDayYear
Date
Signature*

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