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Simply Us Independent Living Facility – Participant Intake & Evaluation Form

Please complete the following questionnaire to help us understand your background and needs. This information will remain confidential and will only be used to determine eligibility and the best fit for our community.

Personal Information

Full Name

Date of birth

Phone *

Email *

Address

Street Address

City

State

Emergency Contacts

Referral & Program Interest

Referred by

Why are you seeking housing now?

Short and Long-Term Goals

Housing History

Current Living Arrangement

Length of Stay / Eviction History

Prior Group Home Experience

Income & Financial Info

Income Sources (Employment, SSI, SSDI, VA, TANF, etc.)

Employer or Agency Details

Monthly Income / Date of Last Payment

SNAP & TANF Amounts

Checking / Savings Accounts Status

Child Support Obligations

Proof of Income + Valid ID Upload

Medical Information

Please provide the name, address, and contact information of your primary care physician.

Primary care physician Name

Primary care physician address

Primary care physician contact

Do you currently have active health insurance?

Yes

Mental Illness Diagnosis

Yes

All Current Medications & Dosages

Diagnosed Illnesses / Physical Limitations

Case Manager or Therapist Contact

Behavioral & Legal Background

Criminal History / Probation or Parole Officer Contact

Pending Cases

Support System & Lifestyle

Family Support / Children / Employment Status

Skills or Training

Alcohol or Drug Use

Program Commitment & Class Participation Agreement

Emergency & Medical Contacts

Two Emergency Contacts with Relationship & Phone

Emergency Contact Name:

Emergency Contact Address

Emergency Contact Phone

Relationship to Participant:

Financial & Payee Authorization

Do you agree to allow Simply Us Independent Living to serve as your monthly representative payee for your benefits or income?

Yes

Savings Program Authorization

You acknowledge and agree that Simply Enterprise will establish a savings account on your behalf and deposit $25 monthly from your income. These funds are intended to assist you upon discharge or voluntary exit from the program.

I Understand and Agree

Monthly Allowance

You acknowledge and agree that Simply Us Independent Living will issue the remaining balance of your funds to you as a monthly allowance after required deductions.

I Understand and Agree

Program Rules & Expectations

You acknowledge and agree that no drugs or alcohol are permitted on the premises. Possession or use will result in immediate discharge from the program.

I Understand and Agree

You agree to maintain personal hygiene, including daily showering, as a required part of program participation.

I Understand and Agree

Do you agree to complete assigned household chores twice weekly to maintain a clean and sanitary living environment?

Yes

Smoking Policy

Smoking is strictly prohibited inside the facility. Smoking is permitted only in designated outdoor areas behind the facility.

I Understand and Agree

Meals & Food Responsibility

You acknowledge that you are responsible for providing your own meals. The program may assist with transportation to food pantries as available.

I Understand and Agree

Participant Acknowledgment

By signing below, you confirm that you understand and agree to comply with all program rules, policies, and expectations outlined above.

Participant Signature:

Clear

Date

Straight talk (because you asked for truth):

This version:

• Protects you legally

• Sets clear expectations

• Eliminates “I didn’t know” excuses

• Reads like a real program, not a casual agreement

Simply Us – The Perfect Living Community

(888) 434-4644 ext 700

[email protected]