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Intake Form
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:
Select
Cell Phone
Car
Loans
Other
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:
List Food/ Beverages:
Other:
Du have ano yoy chronic medical issues we should be cncerned about? (Example:Diabetes, COPD, etc.)Please provide detailos below:
Do you have any special medical equipment?
Have you been exposed to someone with COVID-19?(Circle)
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
Can you participate in household cleaning and chores?(Circle)
Yes
No
Do you bath every day? (Circle)
Yes
No
Do you have any issues with bladder control?(Circle)
Yes
No
Sometimes
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
please
explain
Are you recovering from any addiction that we should be aware of?(Circle)
YES
NO
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
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
SUBMIT
