Dignified Living. Effortless Days. Peace of Mind.
RESIDENT INFORMATION
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Female
Male
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail:
example@example.com
Phone:
Format: (000) 000-0000.
HOUSING INFORMATION
HOUSING INFORMATION
Rows
Living Preference
Move-In Timeline
3-Month
6-Month
Month-to-Month
Program Options
3-Month
6-Month
Month-to-Month
Living Preference
Private Master Suite
Closet Equipped Room
Standard Room
Move-In Timeline
Immediate
30 days
Flexible
INDEPENDENT LIVING SCREENING
Please check any of the following that apply to you:
Age 21 or older
No medical care
Communication access
Income or benefits
Veteran
Currently housed
Follows house rules
Experiencing homelessness
Independent mobility
Transportation access
Other
CASE MANAGEMENT CONTACT
Full Name:
First Name
Last Name
Phone:
Format: (000) 000-0000.
Organization:
Form ID: LSH-OR-004
Revised: January 2026
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Resident Intake Form
EMERGENCY CONTACT
Full Name:
Relationship:
Phone:
Format: (000) 000-0000.
Is this person authorized to receive information in an emergency?
Yes
No
Is this person allowed to assist with decision-making if the resident cannot?
Yes
No
HEALTH & WELLNESS
Do you take prescribed medication?
Yes
No
Are you able to manage your own medication?
Yes
No
Do you have any physical limitations that may affect daily living?
Yes
No
RESIDENT ELIGIBILITY SCREENING
Are you willing to live in a drug-free shared environment?
Yes
No
Have you ever been removed from a housing program?
Yes
No
Do you have a history of violent behavior toward others?
Yes
No
Are you currently using illegal drugs or misusing alcohol?
Yes
No
Are you able to manage your daily needs without assistance?
Yes
No
FINANCIAL STABILITY
Do you have a stable source of income or benefits?
Yes
No
Are you able to pay housing fees on time each month?
Yes
No
Form ID: LSH-OR-004
Revised: January 2026
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Resident Intake Form
BACKGROUND SREENING
Are you currently on probation or parole?
Yes
No
Do you have pending legal charges?
Yes
No
Are there any legal restrictions that would affect placement?
Yes
No
If yes, please provide details:
PROGRAM EXPECTATION
I understand this is an independent living home and not a medical facility.
I am responsible for managing my own medications.
I agree to follow all house rules and shared living expectations.
I will maintain cleanliness in my personal and shared spaces.
I understand disruptive behavior may result in removal.
I understand illegal drugs, weapons, and violence are prohibited.
I agree to treat staff and residents with respect.
I understand smoking and alcohol use are prohibited in this home.
RESIDENT GOALS
What goals would you like to work toward while living here?
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Resident Intake Form
HOUSE ACKNOWLEDGMENT
I acknowledge that I have reviewed the house rules and agree to follow all policies while residing in the home.
Yes
No
LIABILITY STATEMENT
I understand Medi-Ride Solutions provides independent housing only and is not responsible for personal belongings, medical care, or supervision.
Yes
No
FINAL SCREENING QUESTION
Why do you believe you are a good fit for shared independent living?
Resident:
Date:
Management Use Only
Application Approve
Additional Information Needed
Not a Fit at This Time
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PROGRAM CRITERIA
ELIGIBILITY REQUIREMENTS CHECKLIST
Purpose of This Form
This form outlines the general eligibility criteria for residency at Medi-Ride Solutions an independent living residence. Eligibility is based on the ability to live independently within a shared housing environment and is not an automatic guarantee of admission.
ELIGIBILITY CHECKLIST
ELIGIBILITY CHECKLIST
Able to manage personal care independently
Understands that Medi-Ride Solutions does not provide medical care
Willing to live in a shared residential environment
Able to respect shared spaces, house rules, and community expectations
Willing to participate in a structured but non-supervised living setting
Meets the minimum age requirement for residency
Residency Eligibility Criteria
Residency Eligibility Criteria
Age 21 years or older
Valid photo identification
Has a source of income, benefits, or support
Veteran, or Adult experiencing homelessness or housing instability
Transitioning from structured environments
Reentry participants (citizens reentering back into society)
© 2026
Standard Policies and Procedures for Independent Living|
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