Independent Living Homes Client Intake Application
Please complete this form to help us understand your needs and how we can support you. Required fields are marked.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Details
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone
Text Message
Other
Current Living Situation
What is your current living situation?
*
Living independently
With family
Group home
Assisted living
Other
Room Preference
*
Private Room
Shared Room
Support Needs and Goals
What type of support do you need?
Personal care
Household tasks
Transportation
Community access
Other
What are your goals for independent living?
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email Address
example@example.com
Additional Comments
Submit Application
Should be Empty: