Room to Rest - Participation Program Intake Form
Redefining shared community housing through Safety, Stability, Structure, and Support!
Basic Information
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Email Address:
example@example.com
Current Address:
Referred From:
*
Ex: Self, Social Worker, Case Manager, Family Member
Income & Benefits
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
SSI
SSDI
Employment
VA Benefits
Other
If other, please explain:
What is your estimated monthly income?
*
(We may ask for confirmation)
Do you receive Food Stamps (EBT/SNAP)?
*
Yes
No
Do you have a reliable phone number we can use to contact you regarding your application?
*
Yes
No
Independent Living Ability
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
*
Yes
No
If yes, please explain:
Are you currently taking any prescribed medications?
*
Yes
No
If yes, please explain:
Do you have difficulty accessing medications (cost, transportation, insurance, etc.)?
*
Yes
No
If yes, please explain:
Housing Preferences & Needs
What type of room are you looking for?
*
Shared Room
Private Room
Private Room with Bathroom
No Preference
Desired move-in date:
*
-
Month
-
Day
Year
Date
Do you have any physical disabilities or mobility concerns?
*
Yes
No
If yes, explain:
Do you any accessibility needs we should be aware of when placing you in housing?
*
Ground-level/no stairs
Wheelchair accessible
Stairs are okay
No accessibility needs
Back
Next
Background Screening
Have you been evicted from a previous residence?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Lifestyle & House Rules
Are you willing to follow house rules (Ex: No drugs or alcohol, no unapproved guests, quiet hours, cleanliness?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets?
*
Yes
No
Final Notes
Why are you seeking housing at this time?
*
Anything else you would like us to know?
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