Intake Application

Intake Application

Pathway To Independence, LLC
Full Legal Name

First NameLast Name
Preferred Name (if different)
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current / Previous Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternate Phone (if any)
Please enter a valid phone number.Format: (000) 000-0000.
Identification Government-issued ID provided
Identification Type

Other
ID Number (if recorded)
State Issued
Expiration Date

MonthDayYear
Date
Employment / Education Current Status
Employer / School Name
Primary Source of Income

Other
Monthly Income (optional)
Responsible for Rent/Program Fees

Other
Medical Conditions
Prescribed Medications
Allergies
Primary Care Provider (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Mental Health & Support
Agency / Provider
Are you currently on probation or parole?
Do you have any active restraining orders?
Explanation if yes
Primary Transportation Method
Driver’s License
Vehicle
How did you hear about this program?
Reason for seeking independent living
Expected Length of Stay (if known)
Agreements & Acknowledgments: Please read and understand the program rules, violations, and certification.
Email
example@example.com
Resident Name (Print)
Resident Signature
Date

MonthDayYear
Date
Should be Empty: