Independent Living Pre-Screening/Intake Form

1. Full Name:

2. Date of Birth:

3. Phone Number:

4. Email Address (if available):

5. Current Address:

6. Where were you referred from? (Agency, case manager, family member, self, etc.)

7. Do you have a steady source of income?

Yes No

8. What is your main source of income?

SSI SSDI Employment VA Benefits Other:

9. What is your estimated monthly income?

10. Do you receive Food Stamps / EBT (SNAP benefits)?

Yes No

11. Do you have a working phone we can use to contact you?

Yes No

12. Are you able to live independently without daily assistance?

Yes No

13. Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?

Yes No

14. Are you currently taking any prescribed medications?

Yes No

15. Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?

Yes No

16. What type of room are you looking for?

Shared Room Private Room Private Room with Bathroom No Preference

17. When do you need housing? (Move-in date):

18. Do you have any physical disabilities or mobility concerns?

Yes No

19. Have you ever been evicted from a previous residence?

Yes No

20. Have you ever been convicted of a felony?

Yes No

21. Are you a registered sex offender?

Yes No

22. Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?

Yes No

23. Do you smoke?

Yes No

24. Do you have any pets?

Yes No

25. Why are you seeking housing at this time?

26. Is there anything else you'd like us to know?

PRE-SCREENING/INTAKE FORM

Basic Information

Income & Benefits

Independent Living Ability

Housing Preferences & Needs

Background Screening

Lifestyle & House Rules

Final Notes