Client Readiness Form – Dignified Living Communities

Client Readiness Form – Dignified Living Communities LLC

This form helps Dignified Living Communities determine whether a client is ready for community-based residential placement. We use this information to ensure safety, stability, and appropriate support levels.

Client Information

Client Full Name Date of Birth Phone Number Email (optional)

Income & Identification

Monthly Income Source Upload ID

Housing Readiness

Please answer honestly to ensure proper placement.

Can you live safely in a shared home environment? Do you require assistance with daily living tasks? Do you take medication? Mobility Status

Behavioral & Safety Considerations

Any history of behaviors that may impact shared living? Are you currently under supervision, parole, or court requirements? If yes, please describe requirements:

Emergency Contact

Full Name Phone Relationship

Agreement & Signature

By signing below, you acknowledge that the information provided is true and that you are willing to participate in a community living program with shared expectations, structure, and house guidelines.

Digital Signature (Type Full Name)

Thank you! Your readiness form has been submitted. Our placement team will contact you with next steps.