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Simply Us Independent Living Facility – Participant Intake & Evaluation Form

Please complete the following questionnaire to help us understand your background and needs. This information will remain confidential and will only be used to determine eligibility and the best fit for our community.

Personal Information

Full Name

Date of birth

Phone *

Email *

Address

Street Address

City

State

Emergency Contacts

Referral & Program Interest

Referred by

Why are you seeking housing now?

Short and Long-Term Goals

Housing History

Current Living Arrangement

Length of Stay / Eviction History

Prior Group Home Experience

Income & Financial Info

Income Sources (Employment, SSI, SSDI, VA, TANF, etc.)

Employer or Agency Details

Monthly Income / Date of Last Payment

SNAP & TANF Amounts

Checking / Savings Accounts Status

Child Support Obligations

Proof of Income + Valid ID Upload

Health & Wellness

Physician Contact Info

Mental Illness Diagnosis

Yes

No

All Current Medications & Dosages

Diagnosed Illnesses / Physical Limitations

Case Manager or Therapist Contact

Behavioral & Legal Background

Criminal History / Probation or Parole Officer Contact

Pending Cases

Support System & Lifestyle

Family Support / Children / Employment Status

Skills or Training

Alcohol or Drug Use

Program Commitment & Class Participation Agreement

Emergency & Medical Contacts

Two Emergency Contacts with Relationship & Phone

Acknowledgement & Signature

I certify that the information is accurate”

Signature

Clear

Date

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Simply Us – The Perfect Living Community

(888) 434-4644 ext 700

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