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Application
Intake Form
1
Contact Info
2
Emergency Contact Info
3
Employment status
4
Method of Payment
5
Background History
6
Referral Source
Date
Current Address
SSN #
D.O.B
Contact Phone #
Contact Email
Preferred Method of Contact?
Preferred Method of Contact?
Phone
Email
Gender
Gender
Male
Female
Occupation
Next
Emergency Contact Name
Relationship to Applicant
Emergency Contact Phone #
Contact Email
Previous
Next
Are you employed?
Are you employed?
Yes
No
Place of Employment
Part-Time /Full-Time
Select
Part-Time
Full-Time
Previous
Next
Method of Payment
Select
SSD/SDDI
Self Pay
Other
Previous
Next
Have you ever lived in Shared/ Independent living facility before?
Select
Yes
No
If so, how long and what caused you to leave?
Do you smoke?
Select
Yes
No
Do you drink?
Select
Yes
No
Are you mobile?
Select
Yes
No
Are you recovering for any substance abuse?
Select
Yes
No
Are there any medical or mental health concerns?
Are you a registered sex offender?
Select
Yes
No
Previous
Next
Who referred you?
Select
Self
Social Worker
Nursing facility
Treatment facility
Prison
Other
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