Intake and Screening
Please fill out this form to help us understand your needs and determine your eligibility for our programs.
Email *
Full Name
Date of Birth
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/
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/
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Phone Number
Email
Current Address
Where were you referred from?
Are you able to live independently without daily assistance?
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Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
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Are you taking any prescribed medication?
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Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
Do you have a steady source of income?
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What is your estimated monthly income? (We may ask for confirmation — proof can be shown in person or sent electronically.)
Do you receive Food Stamps / EBT (SNAP benefits)?
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Do you have a working phone we can use to contact you?
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Do you have any children? If so, how many?
Do you have any physical disabilities or mobility concerns?
Have you ever been convicted of a felony? (This will not effect your acceptance)
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Are you a registered sex offender? (This will not effect your acceptance)
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Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?
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Do you smoke?
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Do you have any pets?
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Is there anything else you'd like us to know?
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