Resident Intake Form

Resident Intake Form
-Resident Requirements-

Must be able to live independently with minimal supervision -Must have a stable source of income or approved benefits -Valid ID required at move-in -Must complete an application and intake interview -Must agree to house rules and community standards -No violent or disruptive behavior -Must maintain cleanliness of personal and shared spaces -No illegal drug use or Alcohol on the property -Willingness to participate in a respectful, supportive living environment -Background checks may be conducted on a case-by-case basis
Full Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address: Street/ City/ State Zip
SSN (Last 4 digits)
Gender
Ethnicity (Optional)
Preferred Language
INCOME & HOUSING INFORMATION
Source of Income
Monthly Income Amount
SSI/SSDI Award Letter on File?
Employer Name (if employed)
Reason for Housing Need
Referral Source / Agency
Previous Housing Situation
Length of Homelessness (if any)
HEALTH & SPECIAL NEEDS
Current Medications
Allergies
Any physical disabilities?
Mental health diagnoses (optional)
Require special accommodations?
Current case manager / social worker
Should be Empty:

-Resident Requirements-