INTAKE FORM

 

Housing Information

(For Office Use Only - Resident Do Not Fill This Section)

Home #: Text field

Room #:  Text field

Move-in Date: Date

End Date of Probation: Text field

Rent Amount ($): Text field

Move-in Fee ($):Text field

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resident/Applicant - Please Answer All Questions Below:

 

Resident – General Information

First Name:Client first name

Middle Name: Client middle name

Last Name:Client last name

Nickname:Client nickname

Preferred Pronoun:Client pronoun

Gender Identity:Client gender

Phone Number:Client phone

Email:Client email

Secured Information

Date of Birth: Client birthdate

SSN / ITIN #: SSN

NY State ID /License/CDL #:Text field

Military ID #:Text field

Marital Status:Client marital status

Spouse’s Name:Text field

Spouse’s Phone:Text field

Your Situation (Please check all that applies)

Checkboxes

Financial Information

Do You Receive: (Check all that applies)

Checkboxes

Monthly Income 1 ($):Text field

Source 1:Text field

Monthly Income 2 ($):Text field

Source 2:Text field

Other Monthly Income ($):Text field

Available Savings ($):Text field

Expenses

Cell Phone ($):Text field

Car Loans ($):Text field

Other Expenses ($):Text field

Total Monthly Expenses ($):Text field

Housing Vouchers

If you receive help to pay for housing (check all that applies)

Checkboxes

If other, please provide the name of your voucher program

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Emergency Contact Information

Contact

Medical Information

Do you have medical insurance?

Checkboxes

Type of Medical Insurance (check all that applies)

Checkboxes

Carrier /Insurance Company Name:Text field

Health Card ID #:Text field

Insurance Company Phone Number:Text field

Are You Disabled?

Radio buttons

Please Explain Your Disability

Paragraph

 

Allergies & Dietary Restrictions

Do you have any allergies or dietary restrictions? Please provide details:

Client allergies

Medication Allergies

List all medications you are allergic to:

Client medical notes

Food & Beverage Allergies

List all foods and beverages you are allergic to:

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Other:Text field

Medical History & Additional Information

Do you have any chronic medical conditions we should be aware of?
(Examples: Diabetes, COPD, etc.)
Please provide details:

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Do you use or require any special medical equipment?
Please provide details:

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Have you been exposed to someone with COVID-19?
Radio buttons

If yes, please explain:

Paragraph

Are you currently experiencing any of the symptoms listed below?

Checkboxes

Resident Suitability Questionnaire

 

Can you walk independently?

Radio buttons

 If No, or Sometimes, Explain:

Paragraph

Daily Living & Personal Care

Can you participate in household cleaning and chores?
Radio buttons
If No or Sometimes, please explain:

Paragraph

Can you bathe and dress yourself?
Radio buttons
If No or Sometimes, please explain:

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Do you bathe every day?
Radio buttons
If No or Sometimes, please explain:

Paragraph

Do you have any issues with bladder control?
Radio buttons
If No or Sometimes, please explain:

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Legal Information

Are you currently on probation or parole?
Radio buttons

If yes, please provide details:

• Probation / Parole Officer Name:Text field
• End Date: Text field
• Contact Phone Number:Text field
• CDC #:Text field

Lifestyle

Do you smoke?
Radio buttons

If yes, please explain. What do you smoke and how much?

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Do you drink alcohol?

Radio buttons

If yes, how much alcohol do you drink per day?

Paragraph

Health & Lifestyle

Are you recovering from any addiction that we should be aware of?
Radio buttons

If yes, please explain:

Paragraph

What time do you normally go to bed?

Text field

Do you have any regular medical appointments?
Please explain:

Paragraph

Food Preferences:

 

Foods You Do Not Like

• Meats: Text field
• Vegetables:Text field
• Other:Text field

Favorite Foods

• Meats:Text field
• Vegetables:Text field
• Other:Text field

Personal Preferences & Compatibility

List activities you enjoy:Paragraph

Do you have any concerns about living with a roommate?
Please explain:Paragraph

Work & Additional Information

Do you work or volunteer anywhere?
Please provide details:

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Is there anything else we should be aware of or concerned about?
Please provide details:

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Acknowledgment

I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of admission or eviction.

• Signature: Signature
• Date:Date

 

 

 

 

 

OFFICE USE ONLY (Skip this section and click submit form):

 

 

Temperature Check (enter temp taken)	Text fieldF
Copy of ID/CDL	Text field
Copy of Proof of Military Service**	Text field
Proof of Income - Confirmation	Text field
Move-In Fee Received	Text field
Deposit Received	Text field
Initial Rent (Prorated) Received	Text field
COVID-19 Disclaimer Signed	Text field
License Agreement Signed	Text field