General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your gender?
Client gender
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status
Insurance & Financial Information
How do you plan to pay for rent?
* Last two pay stubs (Must provide copies before move-in)
* W-2 (Must provide copies before move-in)
* Other source of payment (Explain below)
Explain your source of income or financial support for rent:
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Enter your insurance provider(s).
Insurance
Medical History & Risk Assessment
Tell us about your health background.
1) Do you have any allergies? (List all, if none, type "None")
Client allergies
2) Are you currently prescribed any medications? (List all)
Medication
3) Have you ever attempted suicide?
Checkboxes
3.1) If yes, please provide details (dates, treatment received)
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4) Have you ever engaged in self-harm (e.g., cutting)?
Checkboxes
4.1) If yes, please provide details
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5) Have you ever overdosed?
Checkboxes
5.1) If yes, please provide details (substance, date, medical intervention)
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6) Do you own a firearm or have access to one?
Checkboxes
Living Arrangements & House Rules Compliance
1) Do you have a valid driver’s license?
Checkboxes
2) Do you plan to have a car on the property?
Checkboxes
2.1) If yes, please provide:
Car Make & Model: Text field
License Plate Number: Text field
3) Do you have an emotional support animal (ESA) you wish to bring?
Checkboxes
3.1) If yes, you must provide ESA documentation before move-in
4) Who will be visiting you at the house? (List names & relationship to you)
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