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Home Summary

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Room#

Move-In Date

Rent Amt. ($)

End of Probation

Fee/Deposit ($)

Resident -General Information

First Name:

Middle Name:

Last Name:

NickName:

Preferred Pronoun:

Gender Identity:

Phone :

Email: _

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:

What is the total of your monthly expenses? $

Emergency Contact Information

First Name:

Last Name:

Phone #:

Email:

Relationship To You:

First Name:

Last Name:

Phone #:

Email:

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 Sometimes

If No or Sometimes Explain:

Can you bath and dress yourself? (Circle)

Yes No Sometimes

If No or Sometimes Explain:

Do you bath every day? (Circle)

Yes No Sometimes

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?

List food items that you do not like:

Meats:

Vegetables:

Other:

List your favorite foods:

Meats:

Vegetables:

Other:

Resident Suitability Questionnaire Continued

List 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.

The information Ihave provided above is true and accurate to the best of my knowledge. Iunderstand that if Ihave not provided true and accurate information that it will be grounds for eviction.

Signature:

Date:

OFFICE USE ONLY: Circle Yes if applicable

Temperature Check (enter temperature taken)

Copy of ID/CDL

Yes

Copy of Proof of Military Service**

Yes

Proof of Income -Confirmation

Yes

Move-In Fee Received

Yes

Deposit Received

Yes

Initial Rent (Prorated) Received

Yes

COVID-19 Disclaimer Signed

Yes

License Agreement Signed

Yes

Pool Waiver Signed

Yes

Fresh Staart Co-Living provides a safe, supportive, and structured environment for individuals committed to recovery. Our mission is to help residents rebuild their lives with stability, accountability, and purpose.

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Freshh Staart
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Contact Info

Boston, Massachusetts, USA
(617) 752-8489
info@freshstaart.com