Care First Living Intake Form

Care First Living Intake Form
Thank you for your interest in Care First Living.
Please complete this application in full. This application helps us determine eligibility for placement in our independent living housing program. Submission of this application does not guarantee acceptance.

All information is kept confidential.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at your current address(if applicable)?
Are you currently employed or have a source of income?
If yes, Employer name
Job Title
How long have you been employed there?
Do you have additional source of income?
If yes, please explain
Why are you seeking independent living housing?
Do you have any children that will be transitioning into the housing program with you if accepted? If yes, how many and what are the age/s?
Have you ever been evicted?
If yes, Please explain
Have you been discharged from a shared housing program/boarding home?
If yes, Please explain
Are you willing to follow house rules and program structure?
Are you currently taking any prescribed medications?
If yes, Please explain.
Do you have any open legal cases?
If yes, Please explain
Are you able to care 100% for yourself?
Do you agree with shared living?
How do you handle disagreements?
Do you have reliable transportation?
Do you have a case manager, parole officer, or advocate? If yes, please list which one and add name and phone number.
Are you currently in recovery or sobriety?
If yes, please explain
“Have you ever been convicted of a crime? If yes, please explain.”
Are you comfortable with background screening?
At this time in your life, what are you needing help with the most to move you to your next level in life? Stability, accountability, support, or a fresh start? Please explain in detail.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: