Intake Form

Please complete all sections accurately. This information is kept confidential.

Personal Information

Member Name

Date of Birth

Phone Number

Current Address

Name

Relationship

Phone

(We do NOT provide medical care. This section is for safety only.)

Are you able to move independently without assistance?

Are you able to manage your own medications?

Do you have any conditions that affect daily living?

If yes, please explain:

Primary Physician (optional)

(Faith Haven welcomes seniors from all backgrounds while maintaining safety.)

Have you ever been convicted of a violent offense?

Are you currently on parole or probation?

Do you require assistance with cooking, bathing, or mobility?

If yes, supervising officer name & contact:

Monthly Income

Funding Source

I certify that the information provided above is true and accurate.

Signature:

Date: