Independent Living Intake Form

Independent Living Intake Form

Please provide your information to help us assess your needs for independent living services.
What is your full name and date of birth?

First NameLast Name
Date of Birth

MonthDayYear
Date
What is your current address and contact information (phone and email)?

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Are you a veteran?
Are you able to manage your personal care independently including tasks such as bathing, taking your medications, cooking meals, cleaning up after yourself, doing laundry and handling daily self-care tasks, without needing assistance?
Do you have any medical conditions or special needs we should be aware of?
What is your primary source of income (e.g., employment, Social Security Income, pension, V.A. benefits, other)?
If employed, what is your current employer and job title?
If receiving Social Security or other benefits, please list the source, amount, and on what day you receive them.
What type of housing do you currently live in?

Other
Preferred Living
Are you okay with a shared room?
Should be Empty: