Application Form

Resident Intake Questionnaire

Shared Living Community — Dallas, Texas

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)

Please enter the applicant's full name and a phone number or email so we can respond.

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

(Please explain)

Stay Duration

Short-Term Long-Term

Do you have a bank account for automatic withdrawal?

Yes No

Explain Here:

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

Explain Here:

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

Explain Here:

Consent & Acknowledgment

Signature

Sign Here

Date

Please draw a signature before submitting.

Something went wrong and the application wasn't sent. Please try again — or reach us directly at (254) 218-1703 or at info@madjuicolivingcommunity.com. Nothing you entered has been lost.

Resident Intake Questionnaire

Personal Information

Health & Lifestyle

Independent Living Needs

Compatibility & Preferences

Goals & Expectations

Consent & Acknowledgment

Application received