Intake Assessment Form

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Attention: This Form Is For A Shared Bedroom
The monthly bedroom cost per person is $1200
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Please answer each question as honestly and completely as you can. Your answers help us keep our homes safe, peaceful, and supportive for everyone.

Important Instructions
• This form takes about 15–20 minutes to complete.
• Please finish the form in one sitting.
• When you reach the bottom of each page, click NEXT to move forward.
• Do not close your browser or refresh the page, or your answers may be lost.
• At the end, you will be asked to sign before you can submit.

Your form is not complete until you click SUBMIT on the final page.
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Full Name* This field is required.Applicant
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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Email* This field is required.
example@example.com
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Date of Birth* This field is required.
Month
Day
Year
7
Age* This field is required.
8
Gender* This field is required.
Female
Male
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Are you a Veteran?* This field is required.
YESNO
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Are you age 55 or older?* This field is required.
YESNO
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Who is filling out this form?* This field is required.
Me
Caseworker
Family member
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Physician Name
First Name
Last Name
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Physician Phone Number
Area Code
Phone Number
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Emergency Contact Name* This field is required.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
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Where do you live right now?* This field is required.
Apartment
House
Shelter
With Family
Hospital
Homeless
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Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Do you need housing right now?* This field is required.
YESNO
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Have you ever lived with roommates?* This field is required.
YESNO
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Are you able to live in a share home?* This field is required.
YESNO
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Are you okay sharing a bedroom?* This field is required.
YESNO
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Do you need daily medical care?* This field is required.
YESNO
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Can you take your own medicine?* This field is required.
YESNO
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Do you need help bathing or dressing?* This field is required.
YESNO
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Can you use the bathroom by yourself?* This field is required.
YESNO
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Bladder Control* This field is required.
Totally Continent
Needs Routine Toileting or Reminder
Incontinent occasionally
Incontinent daily
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Do you use a walker, cane, or wheelchair?* This field is required.
YESNO
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Have you been in the hospital in the last 30 days?* This field is required.
YESNO
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Your Height* This field is required.
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Your Weight* This field is required.Any recent changes?
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Do you have memory problems?* This field is required.
No
Sometimes
A lot
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Can you make safe choices most of the time?* This field is required.
YESNO
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Are you taking any prescription medication for physical conditions? If yes, what kind and reason?
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Do you have any Allergies?* This field is required.
YESNO
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Special Dietary Requirements
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Mental Health Status* This field is required.
Alert
Oriented
Disoriented
Confused
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Reasoning/Judgment* This field is required.
Good
Poor
Unimpaird
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Have you ever been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder etc)? If so, what was the diagnosis and when did it occur?* This field is required.
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Have you experienced any the following:* This field is required.Check all that apply.
Recent losses or death
Recent fright or shock
Chronic illness
Relationship stress
Recently divorced/separated
Recent or traumatic surgeries, accidents, injuries
Recent job loss
Financial hardship
Working more than 40h per week or two jobs
Being a single parent or primary caregiver (for a parent, child, etc.)
Abuse: sexual/physical/emotional/mental
Parents, siblings or other close family members with a history of addiction or mental illness
Substance use/addiction
Compulsive behaviours (sex/shopping/internet/gambling)
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I would rate my current stress/anxiety on a scale of 0-10 (10 being high)* This field is required.
1
2
3
4
5
6
7
8
9
10
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Can you feed yourself?* This field is required.
YESNO
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Can you get in and out of bed by yourself?* This field is required.
YESNO
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Can you walk around the house safely?* This field is required.
YESNO
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Can you clean up after yourself?* This field is required.
YESNO
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Can you do simple things like make a sandwich?* This field is required.
YESNO
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Do you need someone with you all time?* This field is required.
YESNO
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Do you smoke?* This field is required.
YESNO
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Do you drink alcohol?* This field is required.
YESNO
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Have you had problems with drugs or alcohol?* This field is required.
YESNO
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Are you respectful of others?* This field is required.
YESNO
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Do you get angry easily?* This field is required.
YESNO
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Are you able to live peacefully with others?* This field is required.
YESNO
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Do you speak and understand English?* This field is required.
YESNO
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Understanding* This field is required.
Unimpaired
Understand Simple Phrases Only
Understand Keywords Only
Understanding Unknown
Not Responsive
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Who do you turn to for support?* This field is required.
Friends
Church
Professionals
Neighbours
Co-workers
Family
Partner
Pets
Other
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Do you get monthly income?* This field is required.
YESNO
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Where does your money come from?* This field is required.Choose all that apply.
Social Security
VA Benefits
Disability
Pension
Other
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Can you pay rent every month?* This field is required.
YESNO
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Do you have a caseworker helping you?* This field is required.
YESNO
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Do you understand this is independent living (not medical care)?* This field is required.
YESNO
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Are you okay sharing space with other seniors or veterans?* This field is required.
YESNO
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Are you willing to be kind and respectful?* This field is required.
YESNO
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Can you follow quiet hours and house rules?* This field is required.
YESNO
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Are you ready to move in within 30 days?* This field is required.
YESNO
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Is there anything else we should know about you?
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Today's Date* This field is required.
Date
Year
Month
Day
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Signature (hold/click and sign with cursor)* This field is required.
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