Independent Living Pre-Screening Questions
Basic Information
1. Full Name:
First Name
Last Name
2. Date of Birth:
-
Month
-
Day
Year
Date
3. Phone Number:
Format: (000) 000-0000.
4. Email Address (if available):
example@example.com
5. Current Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
6. Where were you referred from? (Agency, case manager, family member, self, etc.)
Income & Benefits
7. Do you have a steady source of income?
Yes
No
8. What is your main source of income?
SSI
SSDI
Employment
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VA Benefits
Other
9. What is your estimated monthly income? (Will need proof)
10. Do you receive Food Stamps / EBT (SNAP benefits)?
Yes
No
11. Do you have a working phone we can use to contact you?
Yes
No
Independent Living Ability
12. Are you able to live independently without daily assistance?
Yes
No
13. Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
Yes
No
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If yes, please explain:
14. Are you currently taking any prescribed medications?
Yes
No
15. Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
Yes
No
If yes, please explain:
Housing Preferences & Needs
16. What type of room are you looking for?
Semi- Private Room
Private Room
Private Room with Bathroom
No Preference
17. When do you need housing? (Move-in date):
18. Do you have any physical disabilities or mobility concerns?
Yes
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No
If yes, please explain:
Background Screening
19. Have you ever been evicted from a previous residence?
Yes
No
20. Have you ever been convicted of a felony?
Yes
No
21. Are you a registered sex offender?
Yes
No
Lifestyle & House Rules
22. Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?
Yes
No
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23. Do you smoke?
Yes
No
24. Do you have any pets?
Yes
No
Final Notes
25. Do you have a history of substance abuse? Please explain
26. Why are you seeking housing at this time?
27. Is there anything else you'd like us to know?
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