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
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
Relationship to You*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
YesNo
If yes, please provide the name and organization of the referrer.
Current Living Situation
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?*
Monthly Income (approximate)*
YesNoPartially
Health and Support Needs
YesNo
If yes, please describe your disabilities or health conditions.
Medication managementMobility assistanceCounseling/therapyMeal preparationBathingToiletingfeedingCleaningOther
YesNo
If yes, please list your medications.
Behavioral Screening
YesNo
YesNo
If yes, please explain.*
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?*
YesNo
Transportation
Yes, I have my own vehicleYes, I use public transportationNo, I do not have regular transportation
Additional Information
Please share any additional information or comments.
Agreement and Signature
Signature*

Clear
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