Empower Independent Living Admission Form

Full Name

First NameLast Name

Date of Birth

Date

SSN#

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Gender

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Source of Income

Referral Agency/Name of Refferer:

Mental health diagnosis (if any):

Medications (if any):

History of Substance Abuse

Are you on parole/probation?

Are you a registered sex offender?

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision.

You must be able to manage your own:

Personal hygiene and grooming
Meal preparation and eating
Medication (unless managed by an outside provider)
Mobility and transportation arrangements
Housekeeping and laundry
Daily living responsibilities

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.

Signature

Date

Empower Independent Living Admission Form

Emergency Contact