Restore with Love & Co. LLC
Independent Living Inquiry Form
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address (if available)
example@example.com
Where were you referred from? (Agency, Case Manager, Family member, Self, etc.)
History & Background
Do you have any mental health diagnosis? (Bipolar/Schizophrenia/PTSD/etc.)
Are you currently taking any medication?
Yes
No
If yes, please list
Do you have any allergies?
Yes
No
Not Sure
Are you able to live Independently without any assistance?
*
Yes
No
Are you currently recieving any help with daily activities? (Cooking, cleaning, hygiene)
*
Yes
No
Can you walk up/down stairs?
Do you have any physical disabilities or mobility concerns? If yes, state if you use mobility aids such as walker, wheelchair, cane, etc.
Do you use any kind of tobacco?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you have a history of substance abuse? If yes, what kind of drugs? How long have you used them?
Do you have any difficulty accessing your medications? (cost, transportation to pick it up, insurance?) If yes, explain.
Where was your prior living environment?
Family/Friends House
Homeless
Shelter
Hotel
Other
Have you ever been convicted of a felony?
Yes
No
Are you a registered sex offender?
Yes
No
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Lifestyle & House Rules
Are you willing to follow house rules? (No drugs or alcohol, No guests, quiet hours, cleanliness, etc.)
Yes
No
Do you have pets
Yes
No
When are you planning to move in? (Provide date)
What type of room are you looking for?
Semi Private Room
Private Room
No Preference
Private room with a bathroom
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Income
Do you have a steady source of income?
Yes
No
What is your main source of income?
SSI
SSDI
Employment
VA Benefits
Other
What is your estimated monthly income? (Will need proof)
May you provide proof? If unable to provide at this moment, skip question for now.
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Do you recieve food stamps/ EBT (Snap Benefits)?
Yes
No
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Additional Questions
Do you plan on moving in with an additional person? (children/spouse/etc?) Please note that no children are allowed.
What do you enjoy doing in your free time?
Is there anything else you'd like to share with us? (Comments/questions/concerns)
Are there any community resources you are in need of? (ex: food bank/public transportation access/etc.)
Submit
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