Intake Eligibility Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Medical History

This section helps our care team understand your current and past health conditions to ensure a safe, comfortable living environment and appropriate care planning. Please provide accurate and detailed information about your medical background, including any chronic illnesses, past surgeries, hospitalizations, medications, allergies, and mobility or cognitive concerns.

You may also include information on your primary care provider, preferred pharmacy, and any specialists involved in your care. All

Support Needs

Please indicate any areas where you currently need or may require assistance:

I certify that the information provided in this intake form is accurate and complete to the best of my knowledge. I understand that the purpose of this form is to assist in determining eligibility and appropriate placement within the housing program.