Malaika Homes Housing Application

Thank you for your inquiry regarding our independent living. We offer shared rooms with 2 person max per room. Shared rooms are At this time, we are exclusively processing housing applications for UNACCOMPANIED INDIVIDUALS both men and women. Regrettably, we are UNABLE to accommodate pets, or families with children.

We do have a $250 non refundable community/admin move in fee.   

It's important to note that our housing options are designed for SHARED living arrangements rather than individual occupancy. We appreciate your understanding and cooperation in this matter, and we hope you'll consider our program for your housing needs.

Best regards

Applicant Phone Number?*

Applicant Email?*

Applicant Move in Date?

Date

Who referred you? How did you hear about us? Kindly put name of person/agency and phone number. Give Credit!

Who Is the Application for?

Gender?

Date of Birth

Date

Age?

Height?

Weight?

Are You Pregnant?

Are you Aware that this is a Shared Living home?

Have you lived in a Shared Housing Before?

Current Living Situation?

How long would you like to be a guest at our home? *

Funding Source*

Are you Employed?

If you are employed, what are your hours/shift and what city do you work in?

If you are not, do you intend to apply for a job within 1 month of your arrival in Malaika Homes?

If you don’t intend on working or going to school, etc. explain why not and what you plan on doing with your daytime hours?

Would you consider appointing a Representative Payee to ensure timely rent payments aiding the success of your housing? If not, your rent will be due in advance to assure good faith.

Criminal History

If yes, please provide details of any criminal charges or convictions you have, including the nature of the charges and any associated legal outcomes.

Do you have a probation officer, etc? If so, what is their name, phone number and extention?

Funding Source Details : 1. What is the monthly income that you receive?

Funding Source Details : 2. What is the specific date that your payment is disbursed? 2a. Do you have a guarantor assisting you with the bed-rate fee?

Funding Source Details : 3. Any additional Income Information ie. Part-time job?

Please disclose any existing medical/mental conditions or health concerns that we should be aware of. What have you been diagnosed with, if any?

Do you have any food or drug allergies? If yes, please elaborate.

Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s). If no, do you need to find a meeting to attend? If this doesn’t apply, write N/A

Are you currently taking any medications?

If yes, please provide a list of the medications you are taking, including their names and dosages.

Are you currently taking any medications as part of your recovery treatment? If yes, please specify which one/s.

Do you have a sponsor or are you/will you be actively seeking one? (Please specify) If this doesn’t apply, write N/A

How long have you been in recovery? Please provide details about your recovery journey.

Are you involved in any other support groups or programs related to recovery? If this doesn’t apply, write N/A

Have you completed any rehabilitation or treatment programs? If yes, please provide details. If this doesn’t apply, write N/A

Are you coming from another group home? If yes, please specify which one and for how long you've been living there and the reason for leaving.

Do you have a history of relapse? If yes, please provide details and specify if you have a relapse prevention plan in place.

Do you have any specific needs or requirements related to your recovery journey that you would like us to be aware of?

Do you Smoke?

If yes, what do you smoke?

Do you agree to a drug test prior to your move-in date?

We perform random drug tests. Please complete your Name

First NameLast Name

Sign

Preferred Move In Date?

Date

Any important details we should be aware of, not yet addressed?

Documents? Below you can upload documents that we will require such as ID/ Bank Statement/ SS Award Letter

Attachments