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SERVICING GWINNETT COUNTY, GEORGIA

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Personal Information

First name*

Last name*

Birthday*

Gender*

Phone*

Email*

Housing & Living Situation

Are you currently independent?*

YES

NO

Previous Address*

Current Living Situation (check all that apply):*

Living with a friend

In a car

Shelter

Homeless

Hospital

Shared Living

Other

Health & Wellness

Are you currently taking medications?*

NO

If YES, please list:

Do you have any allergies?*

NO

If YES, please specify:

Do you have any mental health diagnoses?*

NO

If YES, please describe:

Do you consider yourself independent or in need of assistance?*

Independent

Need Assistance

Do you have any disabilities or special needs? *

NO

If YES, please describe:

Do you have health insurance?*

YES

NO

If yes, who is your health insurance provider?

Primary Physician Name:

Primary Physician Phone Number:

Medical Conditions:

Mobility Aids Used (if any):

Cane

Walker

Wheelchair

N/A

Other:

Room Preference

Room Type Preference:*

Private

Shared

Background Information

Do you have a history of substance abuse?*

YES

NO

Are you an ex-offender?*

YES

NO

Have you been convicted as a sex offender?*

YES

NO

Are you currently on probation or parole?*

YES

NO

Placement & Financial Information

When do you need to be placed?*

Do you require assistance with any of the following? (check all that apply)*

Meals

Housekeeping

Transportation

Medication Reminders

How do you plan to pay for housing? (check all that apply):*

SSI

SSDI

Retirement

Job

Other:

Monthly Income Amount ($):*

Proof of Income (Award Letter):*

Attached

Will provide later

File upload

Responsible Party for Billing (if different):

Name:

Relationship:

Contact Information:

Emergency Contact

Full Name*

Relationship*

Phone Number*

Additional Information

Tell us about yourself:*

How did you hear about us?*

Referral

Online

Flyer

Social Media

Other:

Consent & Signature

I acknowledge that the information provided in this form is accurate to the best of my knowledge. I understand that this intake is for an independent living program and confirm that I am an independent client.

Signature*

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Date*

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