RESIDENT INTAKE QUESTIONNAIRE
Independent Living Community Partnership
1. PERSONAL INFORMATION
Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Current Address:
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Emergency Contact (Name & Phone):
*
2. HEALTH & LIFESTYLE
Do you have any mobility limitations?
*
Yes
No
(If yes, please explain):
Any dietary restrictions or special needs?
*
Yes
No
(If yes, please explain):
Do you take daily medications?
*
Yes
No
(Please list):
Any chronic medical conditions or disabilities?
*
Yes
No
(Please explain):
Do you have pets?
*
Yes
No
(Please explain):
3. INDEPENDENT LIVING NEEDS
Do you require assistance with daily tasks?
*
Yes
No
(Please explain):
Preferred living arrangement:
*
Private Room
Shared Room
Preferred move-in date:
*
-
Month
-
Day
Year
Date
Stay Duration:
*
Short-Term
Long-Term
4. COMPATIBILITY & PREFERENCES
Describe your daily routine or lifestyle:
Back
Next
What's important to you in a home environment?
*
How do you handle conflict or disagreements in shared spaces?
*
5. GOALS & EXPECTATIONS
What are your goals while living in this home?
What do you hope to get out of your stay here?
6. CONSENT & ACKNOWLEDGMENT
I certify that the information provided is accurate to the best of my knowledge. I understand that this form is used to determine if the home is a good fit for me and the other residents in this community environment.
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: