Home	Text field	Room #	Text field
Move-In Date	Date	Rent Amount	$Number field
End of Probation	Date	Fee/Deposit	$Number field

 

 

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 #: Client phone Email: Client email 

 

Secured Information 

Date Of Birth: Client birthdate SSN/ITIN #: SSN 

ID/CDL#:Text field Military ID #: Text field  

Marital Status: Client marital status Spouse's Name:Text field

Phone: Number field

  

Financial Information 

Monthly Income 1: $Number field Source 1: Text field

Monthly Income 2: $Number field Source 2:Text field  

Other Monthly Income: $ Number field Available Savings: $Number field

Expenses: Checkboxes Other: Text field  

What is the total of your monthly expenses? $Number field  

 

Emergency Information 

Emergency Contact Information  

First Name: Text field Last Name:Text field

Phone #: Number field Email: Text field  

Relationship To You: Text field

First Name: Text field Last Name:Text field

Phone #: Number field Email: Text field

Relationship To You:: Text field  

 

Medical Information  

Do you have Medical Insurance?  Checkboxes

Provider: Text field Health Card #: Text field  

Contact #: Number field  

Do you have any allergies or dietary restrictions? Provide details below.  

List Medications:  

Text field

List Food/ Beverages:  

Text field

Other:  

Text field

 

Do you have any chronic medical issues we should be concerned about? (Example:  Diabetes, COPD, etc.) Please provide details below:  

Text field

Do you have any special medical equipment?  

Text field

Have you been exposed to someone with COVID-19? Checkboxes

IF YES, please explain: Text field

Are you currently experiencing any of the symptoms listed below? 

Checkboxes

 

Resident Suitability Questionnaire *** 

Can you walk independently? Checkboxes 

If No or Sometimes Explain:Text field

Can you participate in household cleaning and chores? Checkboxes

If No or Sometimes Explain:Text field

Can you bath and dress yourself? Checkboxes

If No or Sometimes Explain:Text field

Do you bathe every day? Checkboxes

If No or Sometimes Explain:Text field

Do you have any issues with bladder control? Checkboxes

If No or Sometimes Explain:Text field

Are you on Probation or Parole? Checkboxes

If Yes, provide information:  

Probation/Parole Officer Name: Text field End Date: Date  

Probation/Parole Contact #: Number field CDC #: Text field

 

Resident Suitability Questionnaire Continued 

Do you smoke? Checkboxes

IF YES, please explain: Text field

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

If Yes Explain:Text field

What time do you normally go to bed? Text field AM/PM  

Do you have any regular medical appointments?

Please explain. Text field

 

List food items that you do not like:  

Meats: Text field

Vegetables: Text field

Other: Text field

List your favorite foods:  

Meats: Text field

Vegetables: Text field

Other: Text field

List Activities you enjoy doing:  

Text field

List concerns you may have living with a roommate?  

Text field

Do you work or volunteer anywhere?  

Text field 

List ANYTHING else we should be concerned about.  

Text field

The information I have provided above is true and accurate to the best  of my knowledge. I understand that if I have not provided true and  accurate information that it will be grounds for eviction.  

Signature: Signature Date: Date

 

 

OFFICE USE ONLY: 

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