Pre Screen Intake Assessment

Pre- Screen Intake Assessment

Apply for a space in our independent living home. Please provide your personal and health information. Note: No medical treatment is provided and applicants must be able to live independently.
Personal Information

Tell us about yourself.
Full Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Health & Independence Information

Please answer the following to help us understand your level of independence.
Do you require any assistance with daily living activities (e.g., bathing, dressing, eating)?
Do you have any medical conditions that may affect your ability to live independently?
If yes, please describe the condition(s):
Are you currently taking any medications that require regular supervision or administration by others?
Disclaimer and Acknowledgement

Please read and acknowledge the following.

Pre- Screen Intake Assessment