Home / Move-In Details

Home

Room #

Move-In Date

Rent Amount ($)

End of Probation

Fee / Deposit ($)

Resident - General Information

First Name

Middle Name

Last Name

Nickname

Preferred Pronoun

Gender Identity

Phone #

Email

Submitter Email

Secured Information

Date of Birth

SSN / ITIN #

ID / CDL #

Military ID #

Marital Status

Spouse Name

Spouse Phone

Financial Information

Monthly Income 1 ($)

Source 1

Monthly Income 2 ($)

Source 2

Other Monthly Income ($)

Available Savings ($)

Cell Phone Expense ($)

Car Loan Expense ($)

Other Expenses ($)

Total Monthly Expenses ($)

Emergency Contact Information

Emergency Contact 1

First Name

Last Name

Phone #

Email

Relationship

Emergency Contact 2

First Name

Last Name

Phone #

Email

Relationship

Medical Information

Do you have medical insurance?

YesNo

Provider

Health Card #

Insurance Contact #

Allergies or Dietary Restrictions

List Medications

List Food / Beverages

Other Medical Notes

Chronic Medical Issues

Special Medical Equipment

Have you been exposed to someone with COVID-19?

YesNo

If yes, please explain

Current Symptoms

FeverDry CoughFlu-like Symptoms

Resident Suitability Questionnaire

Resident Suitability Questionnaire Continued

Do you smoke?

YesNo

If yes, explain

Are you recovering from any addiction we should be aware of?

YesNo

If yes, explain

What time do you normally go to bed?

Do you have regular medical appointments?

Foods you do not like - Meats

Foods you do not like - Vegetables

Foods you do not like - Other

Favorite foods - Meats

Favorite foods - Vegetables

Favorite foods - Other

Activities you enjoy

Concerns living with a roommate

Do you work or volunteer anywhere?

Anything else we should be concerned about

Resident Signature

Signature

Date

SLR Intake Form

Home / Move-In Details

Resident - General Information

Secured Information

Financial Information

Emergency Contact Information

Emergency Contact 1

Emergency Contact 2

Medical Information

Resident Suitability Questionnaire

Resident Suitability Questionnaire Continued

Resident Signature

Office Use Only (Optional)