Resident Intake & Admission Form
Standard online intake and admission form for Total Restoration Independent Living.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Address
*
City / State / ZIP
*
Desired Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Current Housing & Referral Information
Current living situation
*
Own home
With family or friends
Shelter
Transitional housing
Street/unsheltered
Institutional setting
Other
Current living situation - Other
Referral source
*
Agency/case manager
Hospital or treatment center
Social worker
Friend or family
Community organization
Website or online search
Other
Referral source - Other
How did you hear about Total Restoration Independent Living?
What brings you to our program / what are you looking for in housing?
*
Program Eligibility
Program eligibility categories
*
Veteran
Youth
Senior
Disability
Family
Survivor of domestic violence
Low-income
At risk of homelessness
Other
Program eligibility - Other
Housing Preference
Preferred Housing Option
*
Please Select
Single Room
Shared Room
Family Unit
Accessible Unit
Temporary Shelter
Other
Housing-Related Needs or Preferences
Income & Payment Information
Income Sources
*
Employment
Benefits
Child Support
Pension
Self-Employment
Family Support
Other
Income - Other
Primary Income Source
*
Monthly Income
*
Employer/Agency
Income Verification
*
Pay Stubs
Benefit Letter
Bank Statement
Tax Return
Employer Letter
Other
Support Services & Accommodation Needs
Does the applicant receive support from an outside provider or service?
*
Case Manager
Therapist
Home Health Provider
Other Provider
No
Support Provider or Agency
Support Provider Contact
Type of Support
Housing-related accommodation request?
Yes
If yes, describe the accommodation request
Legal / Community Re-Entry
Current supervision status
*
Probation
Parole
Pretrial supervision
Community service
Court-ordered treatment
Other
Current supervision status - Other
Case Manager / Officer
Case Manager / Officer Phone/Email
Applicant Certification
Applicant Signature
*
Applicant Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Program Representative
*
First Name
Middle Name
Last Name
Program Representative Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FOR OFFICE USE ONLY
Date Received
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By
*
First Name
Middle Name
Last Name
Decision
*
Approved
Waitlisted
Denied
Move-In Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assigned Property
Room/Bed
Monthly Housing Fee
Move-In Fee
Office Notes
Submit
Submit
Should be Empty: