Prequalification Form

This questionnaire helps us understand your care needs so we can tell you whether our shared living homes are a good fit. Answer what you can — you can leave anything blank and we will follow up. All information is kept private.

Your contact information

Your name

Phone (optional)

Section 1

Medical Background

Tell us about current and past health conditions.

Primary diagnosis

Secondary conditions

Recent hospitalizations

Ongoing treatments

Allergies

Section 2

Medication Management

How medications are taken and managed each day.

Medication list

Administration method

Self-managed

Side effects

Section 3

Functional Status

Daily activities and how much help is needed.

Activities done independently

Activities requiring help

Mobility level

Fall history

Section 4

Daily Living Needs

Support and equipment needed day to day.

Dietary restrictions

Respiratory equipment

Diabetes management

Wound care

Supervision level

Section 5

Behavioral & Cognitive Screen

Memory, orientation, and safety awareness.

Cognitive impairments

Memory issues

Confusion or wandering

Response to directions

Section 6

Income & Stability

Helps us confirm the home is affordable.

Income source

Ability to pay rent

Benefits needed

Section 7

Goals & Preferences

What a good fit looks like for you.

Preferred environment

Social preferences

Goals for the next 6 months

Prefer to talk? Call 832-420-0291.