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.
1. Full Name*

First NameLast Name
2. Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
3. Gender*

MaleFemale
4. Phone Number*
Please enter a valid phone number.
5. Email Address*
example@example.com
6. Upload proof of ID*

Cancelof
7. Emergency Contact Name*

First NameLast Name
8. Emergency Contact Phone Number*
Please enter a valid phone number.
9. Emergency Contact Relationship*
10. Are you currently homeless?*

YesNoOther
11. Current Living Situation*

Living with a friendLiving in a carLiving in a shelterLiving on the streetsIncarcerated/Halfway houseHospital FacilityShared Housing / Group Housing
12. Have you ever lived in a shared housing environment before?*

YesNo
13. Move-in date needed*

MonthDayYear
Date
14. What type of room is preferred? (Based on availability)*

PrivateShared
15. Do you have any current mental health diagnosis? If yes, please list all diagnosis.*
16. Are you currently receiving treatment or therapy?*

YesNo
17. Have you ever been hospitalized for mental health reasons?*

YesNo
If yes, please describe.
18. List all current medications. If none, please type "None."*
19. Do you have physical disabilities or mobility issues?*

YesNo
If yes, please describe.
20. Have you ever had issues with substance abuse?*

YesNo
21. Are you currently in a treatment recovery program?*

YesNo
22. Do you currently use any substances?*

YesNo
If yes, please specify
23. Have you ever been convicted of a felony? (Your answer to this question does not disqqualify you from the program and services.)*

YesNo
24. Are you currently on parole or probation?*

YesNo
25. Are you a registered sex offender?*

YesNo
26. Are you a U.S. Military Veteran?*

YesNo
27. Do you need case management services?

Health InsuranceFood StampsSSI/SSDIEmployment/Training HelpTransportation ReferralDay ProgramLife Skills TrainingGroup TherapyIndividual TherapyCell-Phone/Tabletclothing Donations
28. Do you receive Food Stamps / EBT (SNAP benefits)?*

YesNo
29. How will you be paying for housing?*

SSI / SSDIRetirementOrganization FundingEmploymentOther
30. Total Amount of Monthly Income *
Upload proof of income*

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31. Do you smoke?*

YesNo
32. Do you have any pets?*

YesNo
33. Do you have any allergies (food, seasonal, etc.)?*

YesNo
If yes, please list.
34. Is there anything else you would like us to know to better support you?
35. How did you hear about Havens for Humanity?*

ShelterFood BankWebsite / Search EngineSocial MediaFlyer/BrochureAt an eventWord of mouth
36. Were you referred by a social worker / case worker or an organization?*

YesNo
Contact Name

First NameLast Name
37. Name of referring agency or organization.
38. Contact Phone Number
Please enter a valid phone number.
39. Contact Email
example@example.com
Note:

Please note, there is a $300 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?*

YesNo
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.
I agree
Resident Signature:*

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Date Signed*

MonthDayYear
Date
Please verify that you are human*
Office Use Only:

AcceptedWaitlistedReferredFollow Up
Should be Empty:

Havens for Humanity Application

How to Qualify

Note: