Alta Lux Living - Pre-Screening Form
Thank you for your interest in Alta Lux Living. Our team will review your information and contact you within 48 business hours. If you have any questions, email info@altaluxliving.com or call 826-203-1040. Alta Lux Living is a supportive independent living program and does not provide medical or clinical services.
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Client Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Prefer not to say
Phone Number
*
Email Address
Preferred Method of Contact
Email
Phone Call
Text Message (SMS)
Current Address
Current Living Situation
*
Please Select
Homeless
Transitional Housing
Hospital
Staying with Friends/ Family
Other
If homeless, how long?
If other, please explain:
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Employment & Income
Employment Status
*
Employed
Unemployed
On Assistance
Retired
Other
Income Source (SSDI, SSI, voucher, etc..)
*
Monthly Income $
*
Required Income Verification Documents (submit one): Most recent pay stub (within last 30 days) SSI/SSDI award letter (current year) Unemployment benefits statement Pension or retirement income statement Bank statement (last 30 days) showing recurring income deposits Benefit Verification
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Additional Background
Do you have a case manager or support worker?
*
Yes
No
If yes, Name and contact info:
Do you have a documented disability?
*
Yes
No
Do you have any Allergies?
*
Yes
No
If yes, please list:
Do you have any medical conditions we should be aware of?
*
Yes
No
If yes, please explain:
Are you currently taking any medication?
*
Yes
No
If yes, please list:
If yes, can you manage independently?
*
Yes
No
Any convictions or legal issues?
*
Yes
No
If yes, please explain:
Are you currently on probation or parole?
*
Yes
No
Do you currently use tobacco or nicotine products (cigarettes, cigar, vaping, etc) ?
*
Yes
No
Are there any current concerns related to substance use (alcohol or drug misuse)?
*
Yes
No
If yes, please explain:
Are you willing to comply with our zero-tolerance policy regarding alcohol, illegal drugs, and substance misuse?
*
Yes
No
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Housing Preference
Comfortable with a shared living environment?
*
Yes
No
Preferred Bedroom
Private Room
Shared Room
No Preference
Pets?
Yes
No
To help maintain a safe and respectful living environment, are you willing to follow all house rules, including maintaining a drug and alcohol free environment, no weapons, observing quiet hours, and keeping shared spaces clean?
*
Yes
No
Do you acknowledge that common areas may be monitored by security cameras for safety purposes?
*
Yes
No
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Confirmation & Authorization
*
I understand that Alta Lux Living is a supportive independent living program and does not provide medical or clinical services.
*
I certify that the information provided in this form is true and accurate to the best of my knowledge
Submit
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