Intake Form

Intake Form for Independent Living

Full Name

Date of Birth

Phone Number

Email Address

Government-Issued ID (Yes/No)

Referring Organisation:

Case Manager/Contact Person

Phone Number

Email Address

Requested Room Type (Shared/Private)

Anticipated Move-in Date:

Length of stay (if known)

Monthly Rent Amount Approved:

Non-Refundable Community fee of $300

Source of Income

Pay Frequency (Weekly/Bi-Weekly/Monthly)

Employer's Name

Address

Position

Phone Number

Rent Paid by (Consumer/Organization/Combination)

Able to live independently? (Yes/No)

Drug-Free Envoirement Acknowledgement (Yes/No)

Do you have any medical concerns we should be aware of?

Willing to follow house rules and shared living expectations (Yes/No))

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number