MIL HoLm (MacEvan Independent Living Housing)

MIL HoLm (MacEvan Independent Living Housing) – Intake Application

Non-Medical Adult Independent Living Housing – Georgia
Client Information

Please provide your personal and emergency contact details.
Full Legal Name*

First NameLast Name
Preferred 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
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Level of Independence

Please indicate your ability to complete the following activities independently.

Please indicate your ability to complete the following activities independently.*

Medical & Equipment

Tell us about any equipment or medication management needs.
NoneWalkerWheelchairOxygenCPAPOther (please specify)
YesNoSometimes
Living Preferences

Let us know your preferred living arrangements.
PrivateSharedNo Preference
QuietSocialBalanced
NoYes
Financial Information

Please provide information about your financial situation.
Monthly Income Source(s)
Monthly Housing Budget Range
VA SUPPLEMENT

Veteran status and benefits.
YesNo
Branch of Service
VA Benefits Received (if any)
YesNoUnsure
Certification

Please review and sign before submitting.
I certify that the information provided is accurate and understand that MIL HoLm provides non-medical independent living housing and does not offer assisted living or skilled care services.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

MIL HoLm (MacEvan Independent Living Housing) – Intake Application