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The Mercy Seat Foundation Intake Form

Birthday
Month
Day
Year
Employee Status
Employed
Unemployed
Student
Retired
Support system?
Yes
No
HEALTH, SAFETY & INDEPENDENCE
Able to live independently & be home alone
Do not require personal care services
Agree to substance-free home
Can follow house rules & respect shared spaces
Mobility Concerns:
Yes
No
Home Health / Therapy in place?
Yes
No

If yes, provider(s) & disciplines (RN, PT, OT, CM):

Registered sex offender?
Alcohol addiction?
Use any drugs?
Yes
No

Medications currently taking:

SUPPORT CONTACTS (IF APPLICABLE)

ACKNOWLEDGEMENTS

• I understand The Mercy Seat Foundation provides shared, independent housing and does not provide personal care services.

• I consent to therapists, case managers, and nurses visiting to support my individual needs as coordinated.

• I agree to maintain a substance-free home and follow all house rules and expectations.

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