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Application

Hope > Application

Congratulations! You are eligible to apply for the HOPE program. Please complete this form to apply for program vacancies.

Please be sure to allow about 5 minutes to complete the form.

Senior Group Home Intake Questionnaire

Personal Info

Full Legal Name

Your Date of Birth

Email

Your Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Relationship

Financial Info

Do you currently receive SSI benefits?

Yes

No

Monthly SSI benefit amount: $

Do you receive any additional income?

Yes

No

If yes, please specify source(s) and amount(s):

Do you have Medicare?

Yes

No

Medicare number

Do you have Medicaid?

Yes

No

Medicaid number

Do you have any other health insurance?

Yes

No

If yes, please provide details:

Health Assessment

How would you rate your overall health?

Excellent

Good

Fair

Poor

Do you have any chronic health conditions? (If so, please list)

Do you take any medications regularly?

Yes

No

If yes, please list all medications and dosages:

Do you need assistance with medication management?

Yes

No

Do you use any mobility aids?

None

Walker

Cane

Wheelchair

Other

If other, please specify

Primary Care Physician's Name and Contact Info

In case of emergency, can you safely exit the HOME within three minutes?

Yes

No

Daily Living Activities

Bathing

Independant

Need Some Assistance

Fully Assisted

Dressing

Independant

Need Some Assistance

Fully Assisted

Grooming

Independant

Need Some Assistance

Fully Assisted

Toileting

Independant

Need Some Assistance

Fully Assisted

Walking/Mobility

Independant

Need Some Assistance

Fully Assisted

Medication Management

Independant

Need Some Assistance

Fully Assisted

Personal Preferences

Do you have any dietary restrictions or preferences?

Yes

No

If yes, please specify

What activities or hobbies do you enjoy?

Do you prefer a private room or are you willing to share?

Private

Shared

Do you smoke?

Yes

No

What time do you typically wake up and go to bed?

Wake Up

Go to Bed

Additional Information

Have you lived in a group home or assisted living facility before?

Yes

No

If yes, please provide details

Why are you interested in our group home?

How did you hear about our facility?

When would you like to move in?

Is there anything else you would like us to know about you?

Documentation Checklist

Please be prepared to provide copies of the following documents:

Photo ID/Driver's License
Social Security card
Medicare/Medicaid cards
SSI award letter (most recent)
Medical records (relevant)
Power of attorney/advanced directives (if applicable)

You can feel free to upload photos or documents here, or provide them in-person.

File Upload (Optional) *hold down CTRL key to upload multiple files

Choose File

Your Signature

Sign Here using your finger or a stylus pen.

Thank you for completing this questionnaire. All information provided will be kept confidential and will help us determine if our group home is a good fit for your needs. Someone from our team will contact you within [timeframe] to discuss next steps.

Signed Date

HOPE provides safe, clean, and beautifully maintained apartments for seniors who want to live independently, surrounded by warmth and connection.

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Portland, OR
(503) 742-3291
contact@hope316.com

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