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Pre Screening Intake Form for Mason Independent Living Program
Full Name
Date of Birth (DOB)
Phone Number
Email Address
Current Address
Gender
Select Gender
Male
Female
Non-binary
Prefer not to say
Other
Who referred you?
Select
Self
Family Member
Case Manager
Other (please specify)
Where are you living right now?
Select
Shelter
Street
Transitional Housing
Friend/Family
Hotel/Motel
Other
What happened at your last place of residence?
Why are you seeking housing at this time?
Do you need or use a wheelchair?
Yes
No
Are you okay with shared living?
Yes
No
When do you need to move in?
Are you currently taking prescribed medication?
Do you have a steady source of income?
Yes
No
What is your main source of income?
Select
SSI
SSDI
VA Benefits
Employment
Support System
Other
Do you have a history of substance or alcohol abuse?
Yes
No
What is your estimated monthly income?
Do you receive Food Stamps / EBT (SNAP Benefits)?
Yes
No
Do you have a working phone we can use to contact you?
Yes
No
Are you able to live independently without daily activity assistance?
Yes
No
Do you have difficulty accessing your medications?
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
Do you have any physical disabilities or mobility concerns?
Do you have any pets?
Yes
No
Do you smoke?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Are you a registered sex offender?
Yes
No
Are you willing to follow house rules (e.g., cleanliness, no unapproved guests, no drugs/alcohol, quiet hours, etc.)?
Yes
No
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