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Elevate and Empower
Independent Living
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Pre- Screening Questionaire
Please take a moment to fill out the form.
First Name
Last Name
Birthday
*
required
Email
Phone
Are you currently homeless or unhoused?
Tell us about yourself...
Are you currently on probation or parole?
*
Required
Yes
No
If yes, officer name & number
Do you agree to live in a drug-and alcohol-free home?
*
Required
Yes
No
Are you a registered sex offender?
*
Required
Yes
No
Have you been convicted of any violent offenses?
*
Required
Yes
No
Are you currently employed?
*
Required
Yes
No
Monthly income source
I confirm that I am 25 years of age or older.
I understand that this residence is a shared living environment.
I understand that this residence is not wheelchair accessible.
I confirm that I am able to independently manage all activities of daily living without accommodations, assistive devices, or personal assistance.
I understand that this is a non-clinical independent living program and does not provide medical, mental health, or personal care services.
Identification
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