Independent Living Intake Form

Independent Living Intake Form

Please complete this form to help us assess your eligibility, preferences, and support needs for our independent living community.
Applicant Information

Tell us about yourself so we can create your applicant profile.
Full legal name*

First NameLast Name
Preferred name
Date of birth*

MonthDayYear
Date
Age*
Gender

FemaleMaleNon-binaryPrefer not to sayOther
Applicant reference ID (if applicable)
Contact Information

Share your current contact details so we can reach you.
Current address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number*
Please enter a valid phone number.
Email address*
example@example.com
Preferred method of contact*

Phone callText messageEmailMail
Referral Information

Tell us how you heard about us.
How did you hear about us?*

SelfFamilyCase ManagerHospitalAgencyOther
Referral agency or contact name (if applicable)
Referral contact phone/email (optional)
Program Fit (Short Screening)
Are you 18 years or older?*

YesNo
Are you seeking non-medical independent living?*

YesNo
Do you require 24-hour medical or nursing care?*

YesNo
Are you able to live independently with structure and guidance?*

YesNo
Estimated timeframe for housing need*

Immediately1–3 months3–6 monthsFlexible
Support Needs
Check all that apply*

Life skills supportCase management / resource connectionEmployment or education supportTransportation coordinationCommunity and social support (Non-medical services only)
Brief statement (optional)
Why are you interested in The Myrtle Clay Community Living?
Consent & Acknowledgment
Consent and Acknowledgment*

I understand this is a non-medical independent living programI understand placement is based on availability and eligibilityI certify that the information provided is true and accurate
Applicant signature (typed)*
Date*

MonthDayYear
Date
Emergency Contact

Provide someone we can contact in case of emergency.
Emergency contact name*

First NameLast Name
Relationship to you*
Emergency contact phone number*
Please enter a valid phone number.
Emergency contact email address
example@example.com
Residency Status

Tell us about your current living situation.
Current independent living status*

Living fully independently without supportLiving independently with some informal support (family/friends)Living independently with formal support services (e.g., home care)Living in an assisted living communityLiving in a skilled nursing or rehabilitation facilityOther
Current living arrangement*

Living aloneLiving with spouse/partnerLiving with familyLiving with roommatesOther
Program Interest

Help us understand what type of independent living you are seeking.
Type of independent living you are seeking*

Standard independent living apartmentIndependent living with optional meal plansIndependent living with enhanced support servicesSenior independent living communityAccessible or adapted unit (e.g., wheelchair accessible)Not sure yetOther
Preferred move-in timeframe*

As soon as possible (within 1 month)1–3 months3–6 monthsMore than 6 monthsUndecided
Daily Living Abilities

Tell us which daily tasks you can do on your own and where you may need support.
Daily living tasks you can complete independently*

Bathing/showeringDressingToiletingTransferring (getting in/out of bed or chair)Walking/mobilityEating/feeding yourselfPreparing mealsHousekeeping (laundry, cleaning)Managing medicationsManaging finances/billsTransportation (driving or using public transit)Shopping for groceries and essentialsOther
Please describe any daily tasks where you currently need assistance or expect to need assistance in the future.
Medical & Support Information

Share any medical or support information that may affect your independent living needs.
Do you have any ongoing medical conditions?*

YesNoPrefer not to say
If yes, please list your medical conditions (optional).
Please describe any current support services you receive (e.g., home health, therapy, personal care) and how often you receive them.
Should be Empty:

Independent Living Intake Form

Applicant Information

Contact Information

Referral Information

Program Fit (Short Screening)

Support Needs

Consent & Acknowledgment

Emergency Contact

Residency Status

Program Interest

Daily Living Abilities

Medical & Support Information