Pre-Application
The Inner Peace Living Housing Program is designed to help those in need to move toward self-sufficiency while residing in a positive, safe and supportive living environment. Please note that this is an application for the wait list and does not constitute acceptance into this program housing. Once your application has been received, staff will reach out to you to learn more about your situation. Thank you!
Email
*
example@example.com
Who are you applying for?
*
Myself
A Client
Family Member
Other
Clients Gender
*
Male
Female
N/A
Client Name
*
First Name
Last Name
Representative Name (if applying on their behalf)
First Name
Last Name
Client Phone Number
*
-
Area Code
Phone Number
Client Representative Phone Number
-
Area Code
Phone Number
Do we have permission to leave a message/text on the numbers provided?
*
Yes
No
Client Date of Birth
*
-
Month
-
Day
Year
Date
Are You Homeless?
*
Living with a friend
Living in a shelter
Living in a car
Living on the street
None of these above, I am still living in my home
What type of housing are you or the client applying for?
*
Veteran Housing
Transitional Housing
Elderly Care Housing
Special Needs Housing
Sober Housing
Independent Senior Living
Student Housing
Other
Are you aware that this is for shared housing?
*
Yes
No
Bedroom Interest
*
Private
Shared Bedroom
No Preference
Preferred Move In Date
-
Month
-
Day
Year
Date
How will you/your client pay?
*
Private Pay (Your job, unemployment, etc.)
SSI
SSDI
Voucher
Other
Do you have any known health issues that we should be aware of?
*
How did you hear about us?
*
Is there anything else you would like to share with us?
*
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