• Image field 1

  • INTAKE FORM

  • Resident - General Information

  • Format: (000) 000-0000.

  • Secured Information

  • Date Of Birth:
     - -
  • Format: (000) 000-0000.

  • Financial Information

  • Expenses: Cell Phone, Car Loans, Other

  • 1

  • Emergency Information

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical Information

  • 2
  • Have you been exposed to someone with COVID-19?
  • Are you currently experiencing any of the symptoms listed below?
  • 3

  • Resident Suitability Questionnaire

  • Can you walk independently?
  • Can you participate in household cleaning and chores?
  • Can you bath and dress yourself?
  • Do you bath every day?
  • Do you have any issues with bladder control?
  • Are you on Probation or Parole?
  • If Yes, provide information:
  • End Date:
     - -
  • Format: (000) 000-0000.

  • Resident Suitability Questionnaire Continued

  • Do you smoke?
  • Are you recovering from any addiction that we should be aware of?

  • List food items that you do not like:

  • List your favorite foods:

  • 5

  • Resident Suitability Questionnaire Continued

  • The information I have provided above is true and accurate to the best of my knowledge. I understand that if I have not provided true and accurate information that it will be grounds for eviction.

  • Date
     - -
  • Should be Empty: