Skip to main content
Hit enter to search or ESC to close
Search
Close Search
Menu
Home
About Us
Who We Serve
Room Options & Pricing
Gallery
Contact Us
Client Intake & Pre-Screening Form
Please complete this form for individuals seeking independent living with ABI Grace Services LLC
Who is completing this form?
(Required)
Client/ Resident
Caseworker/ Agency
Family Member/ Other
CLIENT INFORMATION
Full Legal Name
(Required)
First Name
Last Name
Email
(Required)
Phone
(Required)
Preferred Name (optional)
Date of Birth
(Required)
MM slash DD slash YYYY
Age
EMERGENCY CONTACT
Emergency Contact Name
(Required)
Relationship
Emergency Contact Phone Number
(Required)
INCOME & BENEFITS
Checkbox
Employment
SSDI
SSI
VA
Other
INDEPENDENT LIVING REQUIREMENTS
Is the individual able to perform daily living activities (bathing, dressing, cooking)?
(Required)
Yes
No
Is the individual able to manage their own medications without staff assistance?
(Required)
Yes
No
Is the individual able to maintain personal hygiene and room cleanliness?
(Required)
Yes
No
Is the individual able to prepare simple meals or used a shared kitchen responsibly?
(Required)
Yes
No
Is the individual able to ambulate (walk or transfer) safely without assistance?
(Required)
Yes
No
Does the individual not require medical supervision, skilled care, or nursing support?
(Required)
Yes
No
Is the individual able to follow house rules and live cooperatively in a shared environment?
(Required)
Yes
No
MEDICAL INFORMATION
Medical Information (optional)
SUBSTANCE & ALCOHOL USE
Currently using drugs or alcohol?
(Required)
Yes
No
Currently in treatment or recovery?
(Required)
Yes
No
LEGAL HISTORY
Criminal background?
(Required)
Yes
No
Probation or parole?
(Required)
Yes
No
AUTHORIZATION & ACKNOWLEDGEMENT
Consent
(Required)
I certify that the information provided in this Client Intake & Pre-Screening Form is true and accurate to the best of my knowledge. I understand that No Place Like Home Community, LLC is a non-medical independent living environment and that submission of this form does not guarantee placement.
(Required)
Close Menu
Home
About Us
Who We Serve
Room Options & Pricing
Gallery
Contact Us
