The Lillian Curt House Intake Form
All information is confidential.
1. Full Name
First Name
Last Name
2. Birth Date
-
Month
-
Day
Year
Date
3. Phone Number
Please enter a valid phone number.
4. Email Address (if available)
example@example.com
5. Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
6. Referral Source: (agency, case manager, hospital, outreach worker, family, self-referral, etc.)
Income & Benefits
7. Do you have a steady source of income?
Yes
No
8. Main Source of Income:
SSI
SSDI
Employment
VA Benefits
Retirement / Pension
Other
9. Estimated Monthly Income: (Proof may be requested at move -in.)
10. Do you receive Food Stamps / EBT (SNAP)
Yes
No
11. Do you have a working phone that we can reach you on?
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, transportation, etc.)?
Yes
No
if yes, explain
14. Are you currently taking any prescribed medications?
Yes
No
15. Do you have difficulty accessing medications (cost, insurance, transportation, etc. )?
Yes
No
If yes, explain
16. Do you require reminders for medications or appointments?
Yes
No
17. Do you have any mental health diagnoses you would like us to be aware of?(Optional, but helpful for placement)
Yes
No
If yes, explain
Housing Preferences & Needs
18. Preferred Room Type:
Shared Room
Private Room
Private Room w/Bathroom
No Preference
19. Preferred Move-In Date:
-
Month
-
Day
Year
Date
20. Do you have any physical disabilities or mobility concerns?
Yes
No
If yes, explain
21. Do you require a downstairs room?
Yes
No
22. Do you have reliable transportation?
Yes
no
22a. If no, do you need a location near a bus route?
Yes
No
Background Screening
23. Have you ever been evicted?
Yes
No
24. Have you ever been convicted of a felony?
Yes
No
25. Are you a registered sex offender?
Yes
No
26. Do you have any pending legal cases?
Yes
No
If yes, explain
Lifestyle & House Expectations
27. Are you willing to follow house rules ( no drugs, no unapproved guests, cleanliness, curfew/quiet hours, respect for others)?
Yes
No
28. Do you smoke cigarettes or vape?
Yes
No
29. Do you drink alcohol?
Yes
No
30. Do you have any pets?
Yes
No
31. How would you describe your cleanliness level?
Very Clean
Average
Needs Improvement
32. Do you have any issues with sharing space with others?
Yes
No
Final Notes
33. Why are you seeking housing at this time
34. Is there anything else you want us to know to help place you properly?
35. Emergency Contact (optional but recommended): Name, Phone, Relationship
Submit
Should be Empty: