ATW Independent Living Services Intake Form

  • ATW Independent Living Services, LLC

    Intake Screening Form
  • Date of Birth
     - -
  • Format: (000) 000-0000.

  • Eligibility Questions

  • Are you 55 years or older?
  • Are you medically cleared to live independently?
  • Can you follow structured house rules?
  • Are you alcohol and substance-free?

  • Financial Information

  • Current Source of Income:      

  • Veteran Status?

  • Estimated monthly income    

  • Are you able to meet program participation fees?

  • Emergency Contact

  • Format: (000) 000-0000.

  • Relationship:      

  • ATW Independent Living Services (ILS)
    Intake Screening Introduction (Ages 55+)
    Thank you for your interest in ATW Independent Living Services.

    ATW ILS provides structured, independent housing for seniors ages 55 and older who are medically cleared for independent living and seeking a stable, respectful living environment. Our program is designed to promote accountability, independence, and housing stability.

    This intake screening allows us to determine:

    Eligibility for our program
    Readiness for independent living
    Compatibility with shared housing
    Overall program fit
    Please note the following important information before completing this form:

    ATW ILS is not assisted living and does not provide medical or personal care services.
    Residents must be able to manage daily living independently.
    We maintain a zero-tolerance substance policy.
    Completion of this form does not guarantee placement.
    All information provided must be truthful and verifiable.
    Our goal is to create a peaceful, structured environment that protects the safety and dignity of all residents. Careful screening ensures that we maintain that standard.

    If you have questions while completing this intake form, please contact:

    ATW Independent Living Services
    Program Director: Ms. Racquel Gist or Jay Tonia 
    Email: atwilservices@gmail.com
    Business: 321-578-9007

    We appreciate your time and look forward to reviewing your information.

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