Pathway Restoration Intake Form
A VisionRise Solutions Inc Housing Initiative
Thank you for your interest in Pathway Restoration. This form helps us better understand your housing needs, interest, and next steps as part of the VisionRise Solutions Inc's housing initiative.
Pathway Restoration is designed as shared housing program, which means most participants will share a bedroom and shared spaces. Private rooms are limited, offered based on availability, and require a $1,200 private room fee monthly.
Acknowledgment
*
I understand Pathway Restoration is primarily shared housing, and most participants share a bedroom. I am willing to participate in shared housing.
Room Preference
*
Shared room (standard)
Private Room (if available $1,200)
Private room acknowledgement
*
I understand private rooms are limited and not guaranteed.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I agree to receive text messages (SMS) from VisionRise Solutions about my request, including links to forms, next steps, scheduling, and program updates. Msg & data rates may apply. Reply STOP to opt out, HELP for help.
*
I agree
I do not agree
Email
example@example.com
Are you fully independent and able to manage daily tasks on your own?
*
Yes
No
If no, briefly explain what support you may need.
Preferred Method of Contact
*
Text
Email
Call
Do you currently have a source of income?
*
Yes
No
How do you receive income? (To be verified)
*
SSI
SSDI
Pension
Self employment
Job
Other
Upon acceptance there is a one-time non-refundable community fee of $175 due in addition to your monthly membership fee. Monthly membership fee prorated based on join date.
*
I understand
Are you currently taking any medications that may impact shared living or that we should be aware of for safety reasons
*
Yes
No
If you’re comfortable sharing, please list the medication(s) and anything we should be aware of (e.g., storage needs, side effects that may affect shared spaces.
Is there anything you'd like us or your future housemates to know?
Do you have any allergies, habits, or routines to mention?
Submit
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