Senior Living Intake Form
Use this form to collect intake, housing history, health, income, support needs, and signature information for senior living placement. Fields should be optional by default unless clearly required in the source document.
Applicant and Intake Details
Date of Intake
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Agency / Name of Referrer
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Last 4 Digits of Social Security Number
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Emergency Contact
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Living Situation and Referral Information
Current Living Situation
*
Please Select
Homeless
Couchsurfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
Current Living Situation - Other
Referral Source
*
Please Select
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Marketing/ Flyer
Referral Source - Agency Name
Referring Contact Name
Referring Contact Phone/Email
Housing Need and Health History
Brief Summary of Situation / Reason for Housing Need
*
Medical & Mental Health History
Mental Health Diagnosis
Substance Use History
Please Select
Alcohol
Drugs
None
Substance Use History - If Yes, Explain
Legal and Supervision Status
Are you currently on parole or probation?
*
Yes
No
Parole/Probation Officer Name and Phone Number
Are you a registered sex offender?
*
Yes
No
Income and Support Needs
Do you have a source of income?
*
Yes
No
Income Source Type
SSI
SSDI
Employment
Other
Income Source - Other
Monthly Income Amount
Any disabilities or accommodations needed?
*
Yes
No
If yes, please explain accommodations needed
Preferred Room Type
*
Please Select
Shared Room
Private Room
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
If no, please explain ADL assistance needs
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Home health care / support service - Agency Name
Acknowledgment and Signatures
Participant Initials
*
Participant Acknowledgment Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant Name
*
First Name
Middle Name
Last Name
Participant Signature
*
Participant Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Name
*
First Name
Middle Name
Last Name
Staff Signature
*
Staff Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: