Intake Form

Welcome To Your New Home
We're so glad to welcome you into your new home. At Pathway To Stability Independent Living, we believe that everyone deserves a safe, stable, and supportive environment to grow. Our independent living program is designed to help you build on your strengths, develop new skills, and take the next steps toward long-term independence.

Welcome home — we're honored to be part of your journey.
Resident Intake Form
Move In Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact Name & Number:
Previous Living Situation:
Any medical or mental health conditions we should be aware of?
Current Medications (if any):

Rent & Fee Agreement
I agree to pay my rent in the amount of $
Payment Frequency
due on the ________ of each period. I understand the policies for $75 late payments and agree to the terms.
Resident Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Staff Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Resident Agreement & Policies
As a resident of Pathway To Stability Independent Living, I understand that I am entering a shared living environment that promotes stability, independence, and personal responsibility. I agree to the following terms:
- I will respect staff, other residents, and the property at all times.
- I will pay rent on time as agreed.
- I will follow the house rules and attend any required meetings.
- I will not use drugs or alcohol while in the home.
- I understand my stay is flexible and based on my personal progress.
- I may remain in the home beyond 6 months if needed for my independence.
Resident Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
House Rules & Expectations
- No drugs, alcohol, or paraphernalia on the property.
- No violence, threats, or harassment.

- Keep your space and common areas clean and tidy at all times.
- No unauthorized guests allowed.
- Curfew is 11:00 PM daily unless otherwise approved
- Respect quiet hours (9:00 PM – 7:00 AM).
- No visitation unless approved in advance by the House Manager
- Participate in chores and community meetings.
- Use respectful language and behavior at all times.
- Laundry/Wash Day is once per week — failure to complete laundry on your assigned day without prior approval will result in a write-up.
I Understand, Failure to follow these expectations may result in disciplinary action or dismissal from housing
Resident Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Drug/Alcohol Testing Consent
I understand that Pathway To Stability Independent Living is a drug- and alcohol-free environment. If I am suspected of using drugs or alcohol on the property, I agree to comply with drug and alcohol screening as required. Refusal to test will result in removal from housing within 24 hours.
Resident Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact Form
Name:

First NameLast Name
Relationship:
Phone Number:
Format: (000) 000-0000.
Any health conditions staff should know in case of emergency:
Name:

First NameLast Name

Relationship:
Phone Number:
Format: (000) 000-0000.
Any health conditions staff should know in case of emergency:
Name:

First NameLast Name
Relationship:
Phone Number:
Format: (000) 000-0000.
Consent to Release Information
I authorize Pathway To Stability Independent Living to communicate with the following agency/individuals regarding my participation in the program:
Agency/Name:
Phone/Email:
This release is valid until I revoke it in writing.
Resident Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Resident Property & Damage Liability Agreement
I understand that Pathway To Stability Independent Living is NOT responsible for any lost, stolen, or damaged personal items while residing on the property.

I also acknowledge that any intentional damage to property—including furniture, fixtures, or shared spaces—may result in immediate removal from housing. In such cases, no rent refunds will be issued for that month.

By signing below, I agree to these terms as a condition of my residency.
Resident Name:

First NameLast Name
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Photo & Media Release (Optional)
I give Pathway To Stability Independent Living permission to use my photo for community events, flyers, and promotional materials. I understand that my personal story will never be shared without my written consent.
Resident Signature (Optional):
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Welcome To Your New Home