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Just Easy Comfort Independent Living Program · Resident enquiry & intake. Tell us about your housing needs so we can discuss the program and next steps with you.
01 · Contact information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
02 · Resident background
Are you a veteran?
Please Select
YES
NO
03 · Income & housing needs
Do you have a steady source of income?
*
Please Select
YES
NO
What is your current living situation?
*
Do you have a criminal history you would like to discuss?
Please Select
YES
NO
Optional. Background information can be discussed privately with the team.
Preferred move-in timeframe
Background information you would like to discuss privately
Optional. You may leave this blank and discuss it with the team.
04 · Independent living & outside support
Any support or accommodation needs you would like to discuss?
Share general needs only. Detailed medical information can be discussed separately with the team.
05 · Outside support & emergency contact
Are you currently working with a housing or support program?
Please Select
YES
NO
Emergency contact name and phone number
*
Include your contact’s name, relationship to you, and telephone number.
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Should be Empty: