Home:	Bill's Place	Room #
Move-In Date	Date	Rent Amount	$900
End of Probation	Date	Fee/Deposit	$250

 

Resident - General Information

First Name: Client first nameMiddle 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 MilitaryID#:Text field

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

Financial Information

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 Text field

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

Emergency Information

Emergency Contact Information

First Name: Text field Last Name:Text field

Phone #: Text field Email: Text field

Relationship To You: Text field

First Name: Text field Last Name:Text field

Phone #: Text field Email: Text field

Relationship To You:: Text field

Medical Information

Do you have Medical Insurance?

Provider: Text field Health Card #: Text field

Contact #: Text field

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

List Medications:

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List Food/ Beverages:

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Other:

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

Client health problems

Do you have any special medical equipment?

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Have you been exposed to someone with COVID-19?

Checkboxes
IF YES, please explain: 

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Are you currently experiencing any of the symptoms listed below? 

Checkboxes

Resident Suitability Questionnaire

Can you walk independently?(Circle) Checkboxes
If No or Sometimes Explain:

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Can you participate in household cleaning and chores?Checkboxes
If No or Sometimes Explain:

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Can you bath and dress yourself? Checkboxes
If No or Sometimes Explain:

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Do you bath every day? Checkboxes
If No or Sometimes Explain:

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Do you have any issues with bladder control?Checkboxes

If No or Sometimes Explain:

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Are you on Probation or Parole? Checkboxes
If Yes, provide information:
Probation/Parole Officer Name: Text field End Date: Text field

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

Do you smoke? Checkboxes
IF YES, please explain:

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Are you recovering from any addiction that we should be aware of?Checkboxes
IF YES, please explain:

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What time do you normally go to bed? Text fieldPM
Do you have any regular medical appointments? Checkboxes

Please explain.

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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:

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List concerns you may have living with a roommate?

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Do you work or volunteer anywhere?Text field

List ANYTHING else we should be concerned about.

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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: SignatureDate: Date