Independent Living Intake Form – Evalena's Safe Solution

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Independent Living Intake Form

ESS Independent Client Intake Form

Newsletter

First Name

Last Name

Date of Birth

Phone Number

Email Address

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact Name

Relationship to Applicant

Emergency Contact Phone Number

Referral Source

Self

Family

Agency

Hospital/Healthcare Provider

Social Worker/Case Manager

VA / Veteran Organization

Other

Agency / Organization Name

Contact Name

Referral Contact Phone Number

Referral Contact Email

Current Living Situation

Own/Rent

With Family/Friends

Shelter/Temporary Housing

Hospital/Facility

Homeless/Unhoused

Other

Veteran Status

Yes

No

Source Of Income

Social Security (SSA)

SSI

SSDI

VA Benefits

Retirement/ Pension

Employment

Other

Approximate Monthly Income

Who Is Responsible For Paying Rent?

Self

Family Member

Guardian/ Representative

Agency/ Organization

Other

Rent Payment Frequency

Monthly

Weekly

Other

Proof / Source of Payment

Additional Payment Notes

Cooking – Independent Living Skill

Needs -Significant Assistant

Needs – Regular Assistance

Needs – Some Assistance

Mostly Independent

Independent

Personal Hygiene – Independent Living Skill

Needs Significant Assistant

Needs – Regular Assistance

Needs – Some Assistance

Mostly Independent

Independent

Medication Management – Independent Living Skill

Needs Significant Assistant

Needs – Regular Assistant

Needs – Some Assistance

Mostly Independent

Independent

Transportation- Independent Living Skill

Needs Significant Assistant

Needs – Regular Assistant

Needs – Some Assistance

Mostly Independent

Independent

Budgeting / Finances- Independent Living Skill

Needs Significant Assistant

Needs – Regular Assistant

Needs – Some Assistance

Mostly Independent

Independent

Mobility or Accessibility Accommodations Needed

Allergies or Important Emergency Considerations

Transportation Needs

What Assistance, If Any, Is Needed to Live Independently?

Why are you interested in Evalena’s Safe Solution

Is there anything else you would like ESS to know?

Application Certification

I certify that the information provided is accurate to the best of my knowledge, and I understand that completing this intake form does not guarantee placement.

Applicant / Authorized Representative Full Name

Date Completed

6650 Rivers Ave. Ste 100 Charleston SC 29406

admin@evalenassafesolution.com

843-604-6800