Independent Living Facility Resident Intake & Admission Form
Please complete all sections to help us evaluate your eligibility and ensure a safe, supportive living environment.
Resident Pre-Screen / Referral Information
Provide initial information to help us determine your eligibility.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Living Situation
*
Referral Source
*
Please Select
Agency
Self
Family
Other
Reason for Seeking Housing
*
Are you independent with daily living?
*
Yes
No
Mobility Limitations (if any)
Do you require medical or nursing care?
*
Yes
No
Mental Health Support Needs
Substance Use Concerns
Monthly Income Source
*
Monthly Income Amount (USD)
*
Are you able to pay the monthly fee?
*
Yes
No
Do you have a representative payee?
Yes
No
Are you able to live respectfully with others?
*
Yes
No
Have you been convicted of a criminal offense?
Yes
No
If so, Please provide details of the conviction(s), including: • Type of offense • Date of conviction • Location (city/state) • Outcome or sentence • Current status (completed, probation, parole, etc.)
Are you currently on probation or parole?
Yes
No
If yes, Please provide the following information: • Name of supervising officer • Agency or department • Phone number • Any housing restrictions (if applicable)
Do you currently have any pending criminal charges?
Please Select
Yes
No
Please describe the pending charge(s) and current court status.
Are you currently required to register as a sex offender?
Please Select
Yes
No
Any housing restrictions or reporting requirements(if applicable)
Do you have any court-ordered housing restrictions?
Please Select
Yes
No
Do you have any safety concerns?
Smoking Status
*
Please Select
Non-smoker
Smoker
Vapes/E-cigarettes
Other
Emergency Contact Name
*
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preliminary Screening Decision
*
Please Select
Eligible
Not Eligible
Pending
Full Resident Intake Information
Please provide detailed information for admission processing.
Full Legal Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Previous Address
Primary Physician Name
Do you self-manage your medications?
*
Yes
No
Allergies
Physical Limitations
Mental Health Diagnoses (optional)
Dietary Needs
Upload Income Verification Document(s)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Payment Method
*
Please Select
Check
Money Order
Electronic Payment
Other
Representative Payee Name (if any)
Daily Living Skills – Please indicate your level of independence:
*
Rows
Independent
Needs Assistance
Unable
Bathing
Dressing
Meal Preparation
Medication Management
Transportation
Financial Management
History of Aggression or Violence
Legal Restrictions or Court Involvement
Safety Concerns in Shared Housing
Monthly Program Fee (USD)
*
Payment Due Date (e.g., 1st of month)
*
Security Deposit Amount (USD)
Late Fee Policy (if applicable)
Resident Signature (Admission Agreement)
*
Date (Admission Agreement)
*
-
Month
-
Day
Year
Date
House Rules Agreement
Please review each rule and acknowledge your understanding.
House Rules – Please confirm you understand and agree to the following:
*
No illegal activity on property
Respect other residents and staff
Maintain cleanliness of personal and shared spaces
Follow quiet hours
Comply with visitor policy
Adhere to smoking policy
Self-management of medications is required
Know and follow emergency procedures
Resident Signature (House Rules)
*
Date (House Rules)
*
-
Month
-
Day
Year
Date
Emergency Information
Provide emergency contacts and medical details.
Full Name (Emergency Information)
*
First Name
Last Name
Date of Birth (Emergency Information)
*
-
Month
-
Day
Year
Date
Primary Emergency Contact Name
*
Relationship to Primary Emergency Contact
*
Primary Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Name
Relationship to Secondary Emergency Contact
Secondary Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Conditions
Allergies (Emergency Information)
Current Medications
Preferred Hospital
Consent & Information Release
Agreement to information sharing and understanding of independent living responsibilities.
Resident Signature (Consent & Information Release)
*
Date (Consent & Information Release)
*
-
Month
-
Day
Year
Date
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