We are a shared rooms home. At the moment, we are exclusively accommodating adults. If you have children, kindly contact us by phone, and I can direct you to a professional who caters to families.
Prestigious Rentals
Independent Living With Dignity
Intake Form/Waitlist
Name *
*
First Name
Last Name
Date of birth *
*
-
Month
-
Day
Year
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Email
example@example.com
Phone Number *
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Are you a Convicted Felon? *
*
Yes
No
If a convicted felon what was your charge?
Do you have any pending cases? *
*
Yes
No
Are you currently on probation? *
*
Yes
No
Rows
Current Experiences/Uses
History Of
Not Applicable
Psychiatric Conditions
Addiction Disorders
Medical Conditions
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Trauma/Abuse
Prescribed Medications
Any Current Health Problems? If so please include problem and current medications.
Rows
Method
Last Use
Age at first use
Drug Type
Drug Type
Drug Type
Principle Source of Income
*
None
Public Assistance
Retirement
Salary
Disabilty
Monthly Income Amount
*
Number of Dependents
Benefits
Medical
Snap
SSD/SSI
Other
Active
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Status
Pending
Unknown
Are you currently working with a agency, case manager, or sponsor?
Yes
NO
If so, what is the agency name and number? Are you ok with us contacting the agency?
Who referred you to Insert Business Name? *
*
Self
Treatment Center
Nursing Facility
Probation/Parole
Other
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Living Situation
Private Residence
Residential Care/Treatment
Hospital
Prison/Jail
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Homeless
Group Home/Shared Living
Reason for Leaving
Have you been homeless within the last six months?
Yes
No
Are you at risk of homelessness?
Yes
No
Have you lived in a shared home setting before? If so when did you last stay? *
*
You will need assistance with the following:
Housing
Medical Care
Education
Cleaning
Mental Health Services
Substance Abuse Services
Securing Benefits
Money/Debt Management
Opening a Bank Account
Taking Medication
Shopping/Meal Prep
We only have double occupancy rooms available, are you ok with sharing a room? *
*
Yes
No
Other
Are you able to pay four weeks or One Month's rent upfront? Starting price is $insert rental amount here *
*
Are you able to pay four weeks or One Month's rent upfront? Starting price is $insert rental amount here
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Are you able to pay a one-time, non-refundable, move-in/move-out/key set-up fee of $insert amount here *
*
Yes
No
Other
Do you plan on staying for at least 3 months? *
*
Yes
No
Other
Anything Else You Would Like For Us To Know?
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