Resident Intake Form — Victory Living Homes

1. Housing Details

Home you were approved for

Planned Move-In Date

2. General Information

First Name

Middle Name

Last Name

Nickname

Preferred Pronoun

Phone Number

Email Address

3. Personal Details

Date of Birth

Marital Status

Spouse's Name

Spouse's Phone

Are you a veteran?

YesNo

4. Financial Information

Monthly Income 1 ($)

Source 1

Monthly Income 2 ($)

Source 2

Other Monthly Income ($)

Available Savings ($)

Monthly Expenses

Cell PhoneCarLoansOther

Total Monthly Expenses ($)

5. Emergency Contacts

Contact 1

First Name

Last Name

Phone

Email

Relationship to You

Contact 2 (optional)

First Name

Last Name

Phone

Email

Relationship to You

6. Medical Information

Do you have medical insurance?

YesNo

Insurance Provider

Provider Contact Number

Allergies or dietary restrictions

Medications

Food / Beverages

Other

Do you have any chronic medical issues we should know about (e.g., diabetes, COPD)? Please describe.

Do you use any special medical equipment?

Do you have any regular medical appointments? Please explain.

7. Resident Suitability

8. Lifestyle & Preferences

Foods you do NOT like

Meats

Vegetables

Other

Your favorite foods

Meats

Vegetables

Other

Activities you enjoy

Do you have any concerns about living with a roommate?

Do you currently work or volunteer anywhere?

Is there anything else we should know?

9. Agreement

The information I have provided is true and accurate to the best of my knowledge. I understand that providing false or inaccurate information will be grounds for eviction.

Full Name as Signature

Today's Date