Participant Intake Form
This housing program is non-medical and designed for adults who can live independently.
SECTION 1: APPLICANT INFORMATION
Full Legal Name:
Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address (if applicable):
Social Security Number (Last 4 digits only):
Government-Issued ID Type & Number:
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SECTION 2: EMERGENCY CONTACT
Emergency Contact Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
SECTION 3: HOUSING HISTORY
Current Housing Status (check one):
Homeless
Transitional housing
Renting
Living with family/friends
Other
Have you lived in shared housing before?
Yes
No
Reason for seeking housing:
SECTION 4: INCOME & PAYMENT INFORMATION
Source of Income (check all that apply):
Employment
SSI / SSDI
Veteran Benefits
Pension
Public Assistance
Other
Monthly Income (approximate): $
Are you able to pay monthly rent consistently?
Yes
No
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SECTION 5: MEDICAL INFORMATION (FOR SAFETY PURPOSES ONLY)
▲ Important Notice:
Virtuous Legacy LLC does not provide medical care, medication management, or personal care services. This information is collected solely for emergency preparedness and resident safety.
General Health
Do you have any medical conditions we should be aware of in case of emergency?
Yes
No
If yes, please list (optional):
Medications
Do you currently take prescribed medications?
Yes
No
Are you able to manage and administer your own medications independently?
Yes
No
Virtuous Legacy LLC does not assist with medication administration.
Mobility & Physical Needs
Do you use any mobility aids?
None
Cane
Walker
Wheelchair
Other
Are you able to move independently without daily assistance?
Yes
No
Mental & Behavioral Health
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Do you have any diagnosed mental health conditions that may impact shared housing?
Yes
No
If yes, please explain (optional):
Are you currently under the care of a mental health provider?
Yes
No
Substance Use Disclosure
Have you had any substance use issues within the past 12 months?
Yes
No
If yes, are you currently in recovery or treatment?
Yes
No
Not applicable
▲ Substance use on the property is prohibited.
SECTION 6: INDEPENDENT LIVING CONFIRMATION
Please initial each statement:
I am able to perform all activities of daily living independently.
I do not require medical or personal care services.
I understand this is a non-medical independent living community.
I agree to follow all house rules and community guidelines.
SECTION 7: BACKGROUND & HOUSE COMPATIBILITY
Have you ever been evicted?
Yes
No
Have you ever been convicted of a violent offense?
Yes
No
(Background checks may be conducted in accordance with Fair Housing laws.)
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SECTION 8: CONSENT & ACKNOWLEDGMENT
I acknowledge that Virtuous Legacy LLC provides housing only and does not offer medical care, personal assistance, or case management services. I certify that the information provided is true and accurate to the best of my knowledge.
Applicant Signature:
Printed Name:
Date:
-
Month
-
Day
Year
Date
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Should be Empty: