Rozaye's Safe Haven
Thank you for your interest in our independent living facility. The information below is being collected to see if you will be a good fit for our community. This is a pre-intake form used solely for the collection of your information and background and DOES NOT constitute placement in our facility.
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date of Birth
Age
Government-Issued ID Type
Please Select
Driver's License
State ID
Passport
Other
Please select what type of identification you have
Government-Issued ID Number
Gender
*
Male
Female
Email
example@example.com
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Section 2: Housing & Background Information
Are you currently homeless or housing insecure?
*
Yes
No
Where are you currently staying?
Reason for seeking independent living housing
Have you ever lived in a sober living or independent living facility before?
*
Yes
No
If yes, where and when?
Have you ever been evicted?
*
Yes
No
If yes, please explain
Section 3: Recovery & Stability (if applicable)
Are you currently in recovery? (Yes / No / Prefer not to say)
*
Yes
No
Prefer not to say
Length of sobriety (if applicable)
Are you currently enrolled in a recovery program, treatment, or counseling?
Are you required to attend meetings (AA/NA/other)?
Do you agree to maintain a drug- and alcohol-free living environment? (Yes / No)
Yes
No
Section 4: Medical & Mental Health
Do you have any medical conditions we should be aware of?
Do you require assistance with daily living activities?
Are you currently prescribed medication? (Yes / No)
Yes
No
Are you able to self-administer your medication? (Yes / No)
Yes
No
Do you have any mental health diagnoses?
Are you currently receiving mental health services?
Section 5: Employment & Income
Are you currently employed? (Yes / No)
Yes
No
Employer Name (if applicable)
Monthly Income Source (employment, SSI, SSDI, other)
Approximate Monthly Income
Are you able to pay weekly/monthly rent consistently? (Yes / No)
Yes
No
Do you need assistance with employment or benefits?
Section 6: Legal History
Are you currently on probation or parole? (Yes / No)
*
Yes
No
Do you have any pending legal cases?
Are you required to register as a sex offender? (Yes / No)
*
Yes
No
Section 7: Lifestyle & Community Living
Are you able to live cooperatively with others?
Yes
No
Are you willing to follow house rules and curfews?
Yes
No
Are you willing to participate in house meetings and responsibilities?
Yes
No
Do you smoke? (Yes / No)
Yes
No
Are you willing to comply with smoking-designated areas only?
Yes
No
Section 8: Personal Goals
What are your short-term goals (3–6 months)?
What are your long-term goals (1–2 years)?
What support do you hope to receive while living at Rozaye’s Safe Haven?
Section 9: Agreements & Acknowledgements
Do you agree to comply with all Rozaye’s Safe Haven house rules and policies?
Do you understand rent is due weekly/monthly and is non-refundable?
Do you agree to random drug/alcohol screenings if required?
Do you consent to background verification?
Applicant Signature
Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: