Bella Oasis Intake Form

  • Bella Oasis Intake Form

    Please provide detailed information to help us understand your housing needs and support you effectively.

  • Basic Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Best time to reach you*
  • Which Are you applying for?*
  • When are you planning to move?*
  • Have you ever lived with others in a shared living situations?*

  • Employment, Income, & Finanial Stability

  • What is your current employment status?*
  • What are your current sources of income?*

  • Medical & Mental Health

  • Do you take any medication?*
  • Do you self-administer? Please note, "we are not a medical facility and cannot administer medication"
  • Do you have any medical conditions or disabilities?*
  • Do you have any mental illnesses?
  • Are you currently prescribed any medications for mental health support?*

  • Substance Use History

  • Have you ever abused alcohol or substances?*
  • If yes, are you interested in support or resources related to substance use?
  • Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.*

  • Transportation

  • How do you usually get around?

  • Program Expectations Agreement

  • Please note, there is a $300 one time program fee that will be due to hold your requested room. Rent is due the day of move in and will be prorated if you move in after the 1st of the month. Do you understand and agree?
  • By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that Bella Oasis is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.
  • Should be Empty: