Intake Form – Enilrun Services

Skip to content

Enilrun Services

Home
About Us
Services
Contact Us
Intake Form

Home
About Us
Services
Contact Us
Intake Form

Schedule Tour

Supportive Housing Inatke Form

Please fill out this form to help us understand your needs and provide appropriate housing support

First name

Last Name

Client's Phone Number

Race

Black/African American Caucasian Hispanic Native American

Gender

Male Female N/A

Date of Birth

Representative's Phone Number

Representative's Name

Emergency Contact Phone Number

Representative's Email Address

What is your current living situation?

Living with a friend Living in a car Shelter Homeless Hospital / Facility Shared Housing

If yes, please describe your disabilities or special needs

Do you have any history of substance abuse?

Yes No

Please provide details

Do you have any disabilities or special needs?

Yes No

Please provide details

Have you been convicted as a Sex Offender?

Yes No

Please provide details

Monthly Income Amount ($)

Do you have any mental health conditions? *

Yes No

Please provide details

Current Income ($)

Do you have health insurance?

Yes No

Additional comments or needs

When does the client need to be placed?

Are you currently on Probation or Parole?

How did you hear about us?

Referral Search Engine / Web Social Media Other

How did you hear about us?

Enilrun Independent Living – Providing safe, dignified housing for seniors and veterans across Georgia.

Quicklinks

Menu

Home
About Us
Services
Contact Us
Intake Form

Get In Touch With Us

Atlanta, GA 30340
914-310-6181
enilrun@qualityservice.com

Scroll to Top

Schedule Tour

Schedule Tour Form

First Name

Last Name

Email

Address

City

State

Zip Code

Date / Time

Supportive Housing Inatke Form

Quicklinks

Get In Touch With Us

© 2025 Enilrun Independent Living. All rights reserved.

Schedule Tour