empoweredlivingconnections.org
404-217-7787
empoweredlivingconnections@gmail.com
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Intake Form
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Intake Form
Full Name
Date of Birth
Phone Number
Email Address (Optional)
Gender Identity
Male
Female
Non-Binary
Prefer to self-describe
Which Best Describes You?
Veteran
Elderly
Adult needing affordable housing during a rough time
Other
If Other, Please Explain
Do you have a service animal or emotional support animal?
Yes
No
Are you willing to live in a shared, drug- and alcohol-free environment?
Yes
No
Are you independent? Can you care for yourself and manage daily routines?
Yes
No
Do you need assistant with daily living? If yes explain
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you have a support team (family, caseworker, etc.)?
Yes
No
Do you have a mental health diagnosis?
Yes
No
Are you currently taking any medications?
Yes
No
If Yes, Please Explain
Have you ever been convicted of a crime?
Yes
No
Are you currently on probation or parole?
Yes
No
Tell us about yourself
Referral Agency
Preferred Move-In Timeframe
Immediately
1-2 Weeks
30 Days
Not sure
Monthly Income
How Do You Plan to Pay for Housing?
SSI
SSDI
VA
SELF PAY
FAMILY SUPPORT
CASE MANAGER
Today's Date
I confirm that the above information is accurate, and I understand someone will contact me within 48 hours.
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