In Take Form – True Abode LLC

PROGRAM INTAKE FORM

Home: Room

Move-In Date:

Rent Amt. $:(per week/per month)

End of Probation: Fee-$300.00 upon move in (non-refundable)

Resident - General Information

First Name:

Middle Name:

Last Name:

Nick Name:

Preferred Pronoun:

Gender Identity:

Phone No.*

Email ID*

Secured Information

Date Of Birth*

SSN/ITIN #:

ID/CDL:#:

Military ID #

Marital Status

Spouse's Name

Phone

Financial Information

Monthly Income 1: $

Source 1:

Monthly Income 2: $

Source 2:

Other Monthly Income: $

Available Savings: $ Expenses: (Cell Phone Car Loans Other, etc)

What is the total cost of your monthly expenses? $

Emergency Information

First Name

Last Name

Phone

Relationship To You

Medical Information

Do you have Medical Insurance?

Provider:

Health Card :

Contact :

Do you have any allergies or dietary restrictions? Provide details below.

List Medications

List Food/ Beverages

Other:

Do you have any chronic medical issues we should be concerned about? (Example: Diabetes, COPD, etc.)

Please provide details below:

Do you have any special medical equipment?

Have you been exposed to someone with COVID-19? (Circle) Yes No IF YES, please explain:

Are you currently experiencing any of the symptoms listed below? (Circle) Fever Dry Cough Flu-like Symptoms

Resident Suitability Questionnaire

Can you walk independently? (Circle) Yes No Sometimes If No or Sometimes Explain:

Can you participate in household cleaning and chores? (Circle) Yes No If No or Sometimes Explain:

Can you bathe and dress yourself? (Circle) Yes No If No or Sometimes Explain:

Do you bathe every day? (Circle) Yes No If No or Sometimes Explain:

Do you have any issues with bladder control? (Circle) Yes No Sometimes If No or Sometimes Explain:

Are you on Probation or Parole? Yes No If yes, provide information:

Probation/Parole Officer Name

End Date

Probation/Parole Contact

CDC

Resident Suitability Questionnaire Continued

Do you smoke? (Circle) Yes No IF YES, please explain:

Are you recovering from any addiction that we should be aware of? (Circle) Yes No IF YES, please explain:

What time do you normally go to bed?(PM)

Do you have any regular medical appointments? Please explain.

List of food items that you do not like:

Meats:

Vegetables:

Other:

List of your favorite foods:

Other:

Vegetables:

List of Activities you enjoy doing:

List concerns you may have living with a roommate?

Do you work or volunteer anywhere?

List ANYTHING else we should be concerned about.