Nivory Independent Living Community

Nivory Independent Living Community

Resident Intake Application
Resident Information
Full legal Name *
Preferred Name
Date of Birth *

MonthDayYear
Date
Age
SSN (Last 4 Digits Only)*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name*
Relationship *
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Housing Information
Are you currently homeless?*

YesNo
Transitioning From

Jail/PrisonTreatment FacilityHospitalShelterOther
If Other, please explain
Desired Move-In Date*

MonthDayYear
Date
Income & Payment Information
Source of Income

EmploymentSSI/SSDIVeteran BenefitsFamily SupportOther
Other income source
Monthly Income Amount *
Are you able to pay housing fees?*

YesNoWith Assistance
Medical & Support Needs
Any Medical conditions we should be aware of?

YesNo
Please explain medical conditions if Yes
Are you currently taking prescribed medications?

YesNo
Do you require assistance with daily living?

YesNo
Please explain assistance needed if Yes
Community Living Agreement
Are you willing to live in a substance-free environment?*

YesNo
Are you willing to follow all house rules, curfew, & program requirements?*

YesNo
Legal & Supervision
Currently on probation, parole, or supervision?*

YesNo
Officer Name & Phone Number
Any Pending court cases?*

YesNo
Personal References
Reference #1 Name, Phone # & Relationship
Reference #2 Name, Phone # & Relationship
Acknowledgment & Signature

Certification & Signature
Resident Signature *
Date Signed

MonthDayYear
Date
Full Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender*

Type option 1Type option 2Type option 3Type option 4
Medical Conditions or Allergies
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Should be Empty:

Nivory Independent Living Community

Resident Information

Emergency Contact Information

Housing Information

Income & Payment Information

Medical & Support Needs

Community Living Agreement

Legal & Supervision

Personal References

Acknowledgment & Signature

Emergency Contact Information