Resident Intake Questionnaire

Co-Living Community — South Dallas, Texas

Step 1 of 6 –

17%

Personal Information

Full Name

Date of Birth

Current Address

Phone Number

Email Address

Emergency Contact (Name & Phone)

Agency / Case Worker (only if applying on someone's behalf — name, organization & contact)

Health & Lifestyle

Do you have any mobility limitations?

Yes No

(If yes, please explain)

Any dietary restrictions or special needs?

Yes No

(If yes, please explain)

Do you take daily medications?

Yes No

(Please list):

Any chronic medical conditions or disabilities?

Yes No

(Please explain):

Independent Living Needs

Do you require assistance with daily tasks?

Yes No

(If yes, please explain)

Stay Duration

Short-Term Long-Term

Do you have a bank account for automatic withdrawal?

Yes No

(If no, please explain)

Compatibility & Preferences

Describe your daily routine or lifestyle:

What's important to you in a home environment?

How do you handle conflict or disagreements in shared spaces?

Are you willing to live peacefully in a shared living environment?

Yes No

(If needed, please explain)

Goals & Expectations

What are your goals while living in this home?

What do you hope to get out of your stay here?

Do you have a monthly verifiable income?

Yes No

(If yes, please explain)

Consent & Acknowledgment

I certify that the information provided is accurate to the best of my knowledge. I understand that this form is used to determine if the home is a good fit for me and the other residents in this community environment.

Signature

Sign Here

Date

Thank you.

A housing coordinator will review your application and reach out within one business day.

Having trouble submitting? Call or text (972) 638-9745 or email info@eloicoliving.com.