Independent Living Pre-Screening Questions

1 Full Name

2 Date of Birth

Date

3. Phone Number

4 Email Address if available

example@example.com

5 Current Address

6. Where were you referred from?

6 Where were you referred from Agency case manager family member self etc

(Agency, case manager, family member, self, etc

7. Do you have a steady source of income?

8. What is your main source of income?

SSI

9. What is your estimated monthly income? (We may ask for confirmation - proof can be shown in person or sent electronically

10.Do you receive Food Stamps / EBT (SNAP benefits)?

11. Do you have a working phone we can use to contact you?

12.Are you able to live independently without daily assistance?

13.Do you currently receive help with daily activities (cleaning, cooking,

If yes please explain

14.Are you currently taking any prescribed medications?

15.Do you have any difficulty accessing your medications (cost,

transportation, insurance, etc?

16.What type of room are you looking for?

17 When do you need housing Movein date

Date

Do you have any physical disabilities or mobility concerns?

Yes

No

If yes, please explain:

Have you ever been evicted from a previous residence?

20.Have you ever been convicted of a felony?

21.Are you a registered sex offender?

22.Are you willing to follow house rules (e.g., no drugs, no unapproved

guests, quiet hours, cleanliness)?

25 Why are you seeking housing at this time

26 Is there anything else youd like us to know