Havens for Humanity Application Form

  • Havens for Humanity Application

  • How to Qualify

    1. Must be physically independent, and able to care for yourself.

    2. Must be comfortable living in a shared living community (shared kitchen, living room, bathroom, and bedroom based on selection and availability.

    3. Must have guaranteed verifiable income. We accept SSI, SSDI, private pay, retirement, veteran benefits, program support, or employment.

    4. Must complete online application, phone interview, and in person interview.

  • 2. Date of Birth (MM/DD/YYYY)*
     / /
  • 3. Gender*
  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.
  • 10. Are you currently homeless?*
  • 11. Current Living Situation*
  • 12. Have you ever lived in a shared housing environment before?*
  • 13. Move-in date needed*
     - -
  • 14. What type of room is preferred? (Based on availability)*
  • 16. Are you currently receiving treatment or therapy?*
  • 17. Have you ever been hospitalized for mental health reasons?*
  • 19. Do you have physical disabilities or mobility issues?*
  • 20. Have you ever had issues with substance abuse?*
  • 21. Are you currently in a treatment recovery program?*
  • 22. Do you currently use any substances?*
  • 23. Have you ever been convicted of a felony? (Your answer to this question does not disqqualify you from the program and services.)*
  • 24. Are you currently on parole or probation?*
  • 25. Are you a registered sex offender?*
  • 26. Are you a U.S. Military Veteran?*
  • 27. Do you need case management services?
  • 28. Do you receive Food Stamps / EBT (SNAP benefits)?*
  • 29. How will you be paying for housing?*
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  • 31. Do you smoke?*
  • 32. Do you have any pets?*
  • 33. Do you have any allergies (food, seasonal, etc.)?*
  • 35. How did you hear about Havens for Humanity?*
  • 36. Were you referred by a social worker / case worker or an organization?*
  • Format: (000) 000-0000.

  • Note:

    Please note, there is a $350 non-refundable one-time enrollment fee that will be due to hold your requested room. The monthly program fee is due the day of your move-in and will be prorated if you move-in after the 1st of the month.

  • Do you understand and agree?*

  • I certify that the information provided is true and complete to the best of my knowledge. I understand that Havens for Humanity is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.

  • Date Signed*
     - -
  • Office Use Only:
  • Should be Empty: