Resident Intake

Full Name: ____________________________

Date of Birth: ___ / ___ / ____

SSN (Last 4): ____

Address: __________________________________________

Phone: ____________________      Email: ____________________

Emergency Contact: ____________________ Phone: ____________________

Federal Income Source(s): __________________________________________

Proof of Income Provided: ☐ Yes ☐ No

Ambulatory: ☐ Yes ☐ No

Mentally Stable & Independent: ☐ Yes ☐ No

Medical/Behavioral Issues Requiring Care: ____________________________

Smoker: ☐ Yes ☐ No Alcohol Use: ☐ Yes ☐ No

Preferred Move‑In Date: ___ / ___ / ____

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