Language*

US Citizen *

Documentation You Already Have In Your Possession (check all that apply) *

Marital Status*

Pregnant*

Do You Understand That Taking Your Medications On Time Is Important? Do You Agree To Medication Monitoring?*

Are You Currently Employed *

Principle Source of Income*

Health Insurance*

Pets/Service Animals*

Smoker*

Veteran*

Do you give Consent for our Company to Review Your History and Physical (H&P)*

Substance Abuse or Recreational Drug Use*

Current Probation/Parole*

Pending Criminal Cases*

Criminal History - Do you agree to a Background Check*

Do you use Assisted Devices*

Addictions *

Victim of Trauma/Abuse *

Require Special Accommodations(Ex. Medication Reminders/Administration, Transfer Assist, Mobility Assist)*

Require Assist with Personal Care (Bathing, Toileting, Dressing, Mobility and Transferring, Meal Prep, Housekeeping)*

Are you able to prepare your own meals *

Already receiving assistance with Personal Care *

Are You Able to Budget and Grocery Shop*

Have Transportation (Medical or Personal)*

Support from Family or Friend*

How did you hear about us?

Are You Aware that Our Program is SHARED HOUSING and that you may be being sharing a room with a roommate of your same sex(gender)?*