Independent Living Pre-Screening Questions
Answer a few questions to help determine your eligibility for independent living.
Basic Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address (if available)
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where were you referred from? (Agency, case manager, family member, self, etc.)
*
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Income & Benefits
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
SSI
SSDI
Employment
VA Benefits
Other
If you answered Other, please provide the source below.
What is your estimated monthly income? (We may ask for confirmation - proof can be shown in person or sent electronically.)
*
Do you receive Food Stamps / EBT (Snap benefits)?
*
Yes
No
Do you have a working phone we can use to contact you?
*
Yes
No
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Independent Living Ability
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
*
Yes
No
If yes, please explain:
Are you currently taking any prescribed medications?
*
Yes
No
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
*
Yes
No
If yes, please explain:
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Housing Preferences & Needs
What type of room are you looking for?
*
Shared Room
Private Room
Private Room with Bathroom
No preference
When do you need housing (Move-in date):
*
-
Month
-
Day
Year
Date
Do you have any physical disabilities or mobility concerns?
*
Yes
No
If yes, please explain:
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Background Screening
Have you been evicted from a previous residence?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
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Lifestyle & House Rules
Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets?
*
Yes
No
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Final Notes
Why are you seeking housing at this time?
*
Is there anything else you'd like us to know?
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