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EST. 2024
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THE SHEPHERD'S VINEYARD
RESIDENT SCREENING APPLICATION
Legal First Name
*
Legal Last Name
*
Address
*
City/State/Zip Code
*
Phone
*
Sex Assigned at Birth
*
Date of Birth
*
Email
*
Do you have guaranteed monthly Income
*
Yes
No
Income & Financial Income Information. (Check all that apply)
*
SSI
SSDI
Social Security Retirement
VA Pension
Other Monthly Income+
Source+
Amount+
Health & Independence (Check all that apply)
*
Are you able to move around independently (walking, wheelchair, etc.)?
Do you require assistance with daily activities, such as, bathing, dressing, or toileting?
Do you have any medical or behavioral health needs that require 24-hour supervision or care?
Are you cognitively aware & able to make your own decisions?
Background and Referral: How did you hear about us?
*
Are you being referred by a case manager, social worker, or agency? * If so who?
*
Is there anything else you'd like us to know about your situation?
*
Emergency Contact
*
Relationship
*
Phone Number
*
Suite Option
Private (single occupancy)
Semi-Private (double occupancy)
Community (3-4 occupancy)
Acknowledgement: By submitting this application, I confirm that all information provided is true and accurate. I understand that The Shepherd's Vineyard provides housing and does not provide medical care, supervision, or personal care services. Signature
*
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Date:
*
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