Intake Form -

Independent Housing Intake Form

Applicant Information

Income Information

Please provide the gross amount (before any deductions or taxes) for all sources of income you currently receive.

1. Employment / Wages

2. Social Security / Disability (e.g., SSDI / SSI)

3. Pension / Retirement

4. Other Verified Income (e.g., VA benefits, trusts)

Total Gross Monthly Income

Emergency Contacts

Primary Contact

Name

Phone

Secondary Contact

Name

Phone

Independent Living Assessment

Have you been diagnosed with a mental health condition that is currently being managed or requires medication to maintain stable independent living?

Yes No

If yes, are you currently engaged with a mental health professional (e.g., therapist, psychiatrist) and able to manage your treatment (e.g., appointments, medication adherence) independently?

Yes, I manage my treatment independently. No, I require assistance with scheduling or adherence.

Note: This information is required solely to assess the Applicant's ability to maintain a safe and independent living environment within a shared community, and determine if any reasonable accommodations are necessary. All information is kept strictly confidential.

Background & Authorization

Have you ever been convicted of a felony or a gross misdemeanor related to violence, property damage, illegal drugs, or sexual misconduct which has not been annulled, expunged, or pardoned?

Yes No

If yes, please provide a brief description (Type of crime, date, and state of conviction)

Background Check Authorization

I hereby authorize Pillar of Hope Residence to conduct an extensive and complete criminal background investigation using the information provided in this application. I understand that failure to provide truthful information or refusal to consent to this background investigation will result in an automatic denial of my application.

I have read and agree to the Background Check Authorization.

Applicant Signature (Type Full Name)

Printed Name

Date

This form collects confidential applicant information for intake review purposes.