Intake Form – Stay Bridgeway Independent Living LLC

Resident Intake Questionnaire

Independent Living Community Partnership

Personal Information

Full Name

Current Address

Email Address

Date of Birth

Phone Number

Emergency Contact (Name & Phone)

Independent Living Needs

Do you require assistance with daily tasks?

Yes

(Please explain)

Preferred living arrangement

Private Room

Shared Room

Stay Duration

Short-Term

Long-Term

Preferred move-in date:

Compatibility & Preferences

Describe your daily routine or lifestyle:

What’s important to you in a home environment?

How do you handle conflict or disagreements in shared spaces?

Goals & Expectations

What are your goals while living in this home?

What do you hope to get out of your stay here?

Are you willing to live peacefully in a co-living environment?

Is the member currently required to register as a sex offender under state or federal requirements?

Making sure we are in compliance for the correct housing and location the selection needs to be correct. Stating “yes” will not disqualify you.

Yes

Are there any legal restrictions, court requirement, probation conditions, or housing limitations that impact placement?

Do you currently receive VA Benefits?

Yes

In the process

Need help completing form

VA Case Worker Name

VA Case Worker Phone

VA Case Worker Email

Does the Member need support, guidance, or referrals related to any of the following?

Do you currently receive VA Benefits?

Transportation resources

Budgeting/financial education resources

Employment or workforce assistance

Mental health resource referrals

Medication reminder support or community referrals

Food and nutrition resources

Independent living/life skills support

Community resources and benefits assistance

Other

Program Overview

Housing placement requires participants to have verifiable income to maintain monthly housing membership fees. Applicants who are not currently income qualified may enroll in our Employment & Income Readiness Program to receive assistance with becoming housing-ready.

Services my include:

Employment referrals
Interview preparation
Workforce development referrals
Vocational training resources
SSI/SSDI application guidance
Veterans benefits referrals
Fixed-income resource navigation
Community resource referrals

Would you like to enroll in our Employment & Income Readiness Program?

Yes

Best day to contact

Morning

Afternoon

evening

Phone/Mobile

Message

Consent & Acknowledgment

I certify that the information provided is accurate to the best of my knowledge. I understand that this form is used to determine if the home is a good fit for me and the other members in this community environment.

Signature

Sign Here

Date