Rift Valley Independent Living Program Intake Form

Rift Valley Independent Living Program Intake Form

Gather essential information for shared housing eligibility
Personal Information
Full Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender*
Emergency Contact
Emergency Contact Full Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to You*
Relationship to you: Others (please specify).*
Referral Information
Were you referred to this program?*

YesNo
Referrer's name*
Referrer's Organization*
Where did you hear about us?*

RoomiesFacebookKangaroomsSpareRoomsAffordable HousingOther: please specify
Current Living Situation
What is your current living situation*

HomelessStaying with friends/familyRentingGroup HomeShelterRehab programOther: please specify
What is your current living situation?*
How long have you been in your current situation?*
Income and Payment Ability
What is your primary source of income?*
What is your primary source of income?*

EmploymentDisability benefitsPensionVA benefitsNo incomeOther: please specify
Employer/Company*
Company Address*
Monthly Income (approximate)*
I have ________ .*

Housing vouchersFood stampsI don't receive any housing/goverment/non-profit assistanceOther resources/assistance
Housing vouchers: How much do you receive per month?*
Food stamps: How much do you receive per month?*
Other resources: How much do you receive per month?*
Are you able to pay rent regularly?*

YesNo
Health and Support Needs
Do you have any disabilities or health conditions?*

YesNo
If yes, please ALL your disabilities and health conditions.*
Do you require any support services? (e.g., medication management, mobility assistance, counseling)*

No, I don't require any support servicesMedication managementMobility assistanceCounseling/TherapyMeal preparationBathingToiletingFeedingCleaningOther: Please specify
Short details about the selected support services (e.g., Nursing assistant visits 3x a week for basic medical services such as monitoring vitals)*
Are you prescribed any medications?*

YesNo
If yes, please list your medications.*
Behavioral Screening
Have you ever been evicted from a previous residence?*

YesNo
If yes, please explain.*
Have you ever been convicted of a crime?*

YesNo
If yes, please explain.*
Do you have any history of substance use or abuse?*

YesNo
Drugs used now or before*
Sobriety date*

MonthDayYear
Date
Sobriety date*

MonthDayYear
Date
Sponsor's name*

First NameLast Name
Sponsor's phone number*
Please enter a valid phone number.Format: (000) 000-0000.
House Compatibility
Do you have any preferences for housemates? (e.g., age, gender, habits)*
Are there any habits or behaviors that would make sharing a home difficult for you?*
Do you have pets?*

YesNo
Sorry, we don't allow pets.*

I agree to move in without pets
Transportation
Do you have access to transportation?*

Yes, I have my own vehicleYes, I use public transportationNo, I do not have regular transportation
Additional Information
Anything you'd like us to know? Please share any additional information or comments.
Move-in Date:*

MonthDayYear
Date
Who is the primary contact for application follow-ups (phone and email)?*

Resident applicantCase ManagerOther - Please enter relationship to you and his/her phone number and email
Case Manager's Name:*
Case Manager's Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Case Manager's Email:*
example@example.com
Agreement and Signature
Signature*
Should be Empty:

Rift Valley Independent Living Program Intake Form

Personal Information

Emergency Contact

Referral Information

Current Living Situation

Income and Payment Ability

Health and Support Needs

Behavioral Screening

House Compatibility

Transportation

Additional Information

Agreement and Signature