Intake Form Individual 1

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Thank you for helping us re-invigorate the Housemate Matching List!

We have created this online form to gather information about those seeking housemates. As you complete the form, please keep in mind:

Asterisks (*) denote mandated fields/questions

If you are filling out information for a household of two people who are seeking a roommate, you will need to complete two forms, one for each individual. Start with one individual and then at the end of the form, you will be given the option to fill out another form, for the second individual.

You can see all the questions in the form by hovering over the page number button at the bottom of the screen and choosing “see all”

You do not need to complete the form in one sitting. To save what you have entered and come back later, hover over the “save” icon on the bottom of the screen and choose “save and continue later.”

Once you have submitted the form, we will transfer the information to a new website, on which you’ll be able to see and browse profiles of individuals seeking housemates in order to facilitate matches.

If you have questions or problems with this form, or if you have suggestions for how to improve it, we welcome your thoughts! Please contact Melissa Mulliken, at 608/206-1818 or melissa@mmulliken.com

Thank you for your assistance.
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Name* This field is required.Please let us know who is filling out this form on behalf of the supported people/person. This is YOUR name- for privacy's sake we will ask for only the initials of the individual(s) being supported in just a minute.
First Name
Last Name
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Email* This field is required.NOTE: We will not use your contact information for any reason other than contacting you regarding the information you share here.
example@example.com
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Phone Number (just in case)* This field is required.NOTE: We will not use your contact information for any reason other than contacting you regarding the information you share here.
Area Code
Phone Number
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Initials of Individual Number One* This field is required.We will request information on the second individual later.
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IMPORTANT: If you are seeking a housemate match for a household of two individuals, please continue through this form providing information on the first individual. At the end of this form, you will have the option to provide information about the second individual. If you have questions or technical issues, please call Melissa at 608-206-1818
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Gender* This field is required.Select gender here
Male
Female
Transgender
Other
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Age Range* This field is required.Select age range of person supported here
18-25
26-35
35-50
50-65
65+
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Date of Submission* This field is required.Today's date
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Urgency* This field is required.Select urgency here
HIGH: Current vacancy; failing supports
MEDIUM: New match needed within a year
LOW: Current roommate not ideal
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Current Vacancy* This field is required.Immediate?
Yes
No
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If Not Immediate, Housing Anticipated Within
1-6 months
6-12 months
12+
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Explain if Needed
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Gender Preference for New Housemate* This field is required.Select gender preference
Male
Female
Transgender
No Preference
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Current Residential Provider and LTC Program* This field is required.List current provider
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Current Long Term Care Program* This field is required.Please select from one of the following
My Choice
Care Wisconsin-Family Care
Care Wisconsin-Partnership
I Care-Partnership
IRIS
Other
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Future Preferences* This field is required.Future provider options
Wants to keep current provider
Wants to change current provider
Willing to negotiate provider
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Contact Information* This field is required.Who should we contact regarding a potential match?
Guardian
Care Manager
Agency Contact
IRIS Consultant
Other
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Contact Name* This field is required.
First Name
Last Name
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Contact Email* This field is required.
example@example.com
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Contact Phone Number* This field is required.
Area Code
Phone Number
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Is nighttime electronic monitoring a possibility or already in place?* This field is required.Select below
Yes, a possibility
No
Already in place
Not sure
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If Electronic Monitoring System is in Place, Please Explain
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Is Accessible Housing Necessary?* This field is required.Select below
Yes, explain below if this option is selected
No
Some
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If Yes, Explain Need for Accessible Housing
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What is the Location of Current Housing?* This field is required.Please provide zip code here
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General Geographical Area of Current Housing
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Is it OK if the Individual Moves from His/Her Current Location?* This field is required.Select below
Yes
No
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Is there a Preferred Location for the New Housing?* This field is required.Select preferred locations
West Side Madison
East Side Madison
North Side Madison
South Side Madison
Outside of Madison
No Preference
Not Applicable
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When Does the Current Lease End?Month/Year
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Is the Current Lease Negotiable?
Yes
No
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List Any Pets that Live with the Individual Currently
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Are Pets OK?* This field is required.
Yes
No
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Pets PreferenceSelect below
Cats only
Dogs only
Other
All pets considered
Not Applicable
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Support Hours* This field is required.Choose the best match for the individual's type of support
20-24 hours per day
15-20 hours per day
10-15 hours per day
5-10 hours per day
1-5 hours per day
Periodic drop-in support
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Other Support Hours? Please Explain Below
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Type of Support* This field is required.
Live-in
Live near
Drop by
Shift Support
Clustered Support
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Other Type of Support? Please Explain Here
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Choose the Best Match for the Individual's Type of Overnight Support* This field is required.Select best option
Awake overnight
Asleep overnight
Night Owl with responder
Night Owl-technology only
Night Owl agency responder
None/Other (please explain)
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Other Type of Overnight Support? Please Explain Here
Huge
Large
Normal
Small
Ok
Ok
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Personal Care Needs* This field is required.Does the individual have personal care needs?
Yes
Some
No
Verbal cues only
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Any Other Care Needs?
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Other Comments/InformationPlease provide any additional information including specific housing needs or non-negotiable cultural practices, etc.
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List 2 things the person supported LOVES
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List 2 things the person supported LIKES
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List 2 things the person supported DISLIKES
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You are finished with individual one.

CLICK ON THE "SUBMIT" BUTTON if you are filling out the form for one individual. You are finished!

If you are entering information about a second individual, CLICK "SUBMIT" and then CLICK HERE to enter information for the second individual in a household of two individuals seeking a housemate.
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Tags
Todo
In Progress
Done
Should be Empty:

CLICK ON THE "SUBMIT" BUTTON if you are filling out the form for one individual. You are finished!

If you are entering information about a second individual, CLICK "SUBMIT" and then CLICK HERE to enter information for the second individual in a household of two individuals seeking a housemate.