Intake Form

Client Information

Full Name

Gender

Male

Female

Other

Date of Birth

Phone/Mobile

Email Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Placement Required

Yes

Stay Duration

Guardian / Responsible Party Information

Full Name

Phone Number

Relationship

Spouse

Son

Daughter

Other

Explain Here

Full Address

Emergency Contact

Relationship

Employer information

Employer Name

Job Title

Employer Contact

Type of Assistance Received

Financial Information

Can you provide your most recent pay stubs or proof of income?

Yes

Are you able to pay non- refundable $50 community fee to complete background verification?

Yes

Do you have a bank account for automatic withdrawal?

Yes

Do you authorize us to proceed with employment, rental, and background verification?

Yes

Are there any financial considerations or constraints we should know about?

Living Preferences & Compatibility

How do you handle conflict or disagreements in shared spaces?

Are you willing to live peacefully in a shared living environment?

Yes

What are your goals while living in this home?

What do you hope to get out of your stay here?

Health Information/Behavioral & Support Needs

Do you take daily medications?

Yes

Current Medications (Name & Dosage)

Attach additional sheet if needed

Choose File

Do you have any behavioural concerns?

Yes

If yes, please describe:

Additional Information

Is there anything else you would like us to consider with your application?

Acknowledgements & Signature

Important: Our program is designed for individuals who can live independently with minimal support. If you require skilled nursing care or 24-hour supervision, this program may not be the right fit. Please contact us to discuss your specific needs.

I hereby certify that the information provided in this application is true and complete to the best of my knowledge. I authorize verification of the information provided.

Applicant Signature

Date

Guardian / Responsible Party Signature

Date

Helping Seniors, Veterans & Professionals Find Safe and Supportive Living

Book your appointment

We accept SSI, SSDI, SSVF, Third party pay, and direct pay.

Required documentation: Valid ID, Social Security Number, Verified Income.

Client Information

Guardian / Responsible Party Information

Employer information

Financial Information

Living Preferences & Compatibility

Health Information/Behavioral & Support Needs

Additional Information

Acknowledgements & Signature

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