Intake Application – Grace of Gladys

Grace of Gladys Independent Living Intake Application. Please complete all required fields. This application does not guarantee placement.

Client’s Full Name

Date of Birth

Sex at Birth

Race

Preferred Phone Number

Email Address

Emergency Contact Full Name

Emergency Contact Phone

Relationship to Client

Representative (If applicable)

Representative Organization

Reason for housing need:

Referral Source, if applicable

Valid ID/ Driver’s License (If no, we will assist)

Birth Certificate (If no, we will assist)

Social Security Card (If no, we will assist)

Allergies Medical History: (does not disqualify you from the program)

Current Medications: (does not disqualify you from the program)

Any Mental Health diagnosis (does not disqualify you from the program)

Any untreated diagnosis of mental illness? (does not disqualify you from the program)

Recovering from Drug or Alcohol Addiction (does not disqualify you from the program)

Substance use history, if any. (does not disqualify you from the program)

Criminal Record (does not disqualify you from the program)

Currently on Probation or Parole (does not disqualify you from the program)

Registered Sex Offender (does not disqualify you from the program)

Do you have a source of income?

Monthly income amount, type 0 if none.

Comfortable living in a shared environment

Preferred room type

Short-term or long-term housing

Do you require first floor accommodations?

Can you manage ADLs independently?

Have need home health support?

Accessibility mobility or accommodations needed?

Grace of Gladys Independent Living Intake Application Please complete all required fields. This application does not guarantee placement. Independent Living & Functionality Acknowledgment Grace of Gladys Independent Living Community provides safe and supportive housing for individuals who are capable of living independently. This program DOES NOT provide personal care, medical treatment, or 24/7 supervision. Residents are expected to manage their personal hygiene, meal preparation, medication (unless managed by an outside provider), mobility and transportation, house cleaning chores. I understand and agree that this program provides HOUSING ONLY. I will be responsible for my personal care, medical needs, and daily living tasks. If selected, I agree to fully comply with all program policies and house rules at all times. Failure to do so will be grounds for being removed from the program without exception.

Yes, I agree.

Services Requested

Desired Move-In Date

Applicant Certification:

I certify that the above information is true to the best of my knowledge. I understand this intake does not guarantee placement into the program.

Applicant’s Full Name (Please Print)

Applicant’s Signature :

Date