Next Chapter at the Stockyards, LLC

Licensee Details (person needing housing):

Licensees or case managers/support services may fill out this pre-screen form.

Once completed, you can reach us by calling 1-888-510-6398 or emailing admin@nextchapterstockyards.com with any questions.

If your pre-screen is approved we will complete a phone interview with you, have you sign the licensee agreement and intake form, collect your payment, and set a move in date.

Licensee Full Name*

First NameLast Name

Licensee Phone Number*

Licensee E-mail

example@example.com

Licensee Preferred Contact Method (check all that apply):*

PhoneEmail

Licensees MUST have each of the following (check all that apply): *

Valid State or Government issues identification cardCurrent SSI/SSDI award letter or other proof of incomeMove-In Costs: First month's Occupation Fee + One Time Pet Occupation Fee & Monthly Pet Fee (if applicable) + Admin Fee (if applicable)

Licensee seeking a shared or private room (select both if either will meet your need):*

Private RoomShared Room

Do you own a personal vehicle?

YesNo

Has Licensee ever lived in a co-housing environment before? If yes, please explain.*

If we ran a background check on the Licensee, what would we find? Be detailed. We remain flexible and review unique situations case by case.*

Does the Licensee have a case manager? If so, please provide their name, organization, and contact information (email/phone).*

Does Licensee have SSI/SSDI? Do they have a rep payee? If not, please specify income or other funding available to Licensee to utilize. Licensees will be asked to show proof of income and/or other funding. If so, please provide the name and contact information for the Rep Payee and be prepared to show the award letter.*

Check "yes" that the Licensee understands we do not provide food, clothing, or hygiene products. This is the sole responsibility of the Licensee.*

Yes

Is the Licensee ambulatory? Able to manage steps? Is Licensee able to cook, clean, and perform daily chores including light housekeeping of their bedroom, common areas, and the bathroom? Is the Licensee able to take and manage their own medication, schedule doctor appointments and arrange transportation independently? Is the Licensee able to manage their own hygiene? If no to any of these, please provide details below.*

We do not provide any services, but welcome 3rd party support services of our Licensees. If Licensees need any long term care or other supports and do not have them, we encourage Licensees to reach out to their local ADRC. Does the Licensee have any long term care supports they will be utilizing?*

YesNo

Who do we contact if a change in behavior, physical, or mental health is noticed? And what is their relationship to the Licensee?*

Is the Licensee requesting to bring a pet? If yes, please provide details below.*

How long as the Licensee been waiting for housing?*

When is the Licensee available for an interview? When would they like to move in?*

Is the Licensee a tobacco smoker? We have designated smoking areas.*

YesNo

We are not a sober living home and do not allow illegal substances. Is the Licensee able to adhere to this rule?*

YesNo

We do not allow overnight guests without permission. Is the Licensee okay with this rule?

YesNo

We like to match Licensees we feel would live well with one another. Is the Licensee more introverted or extroverted? What are their likes and dislikes pertaining to living with others or in general? What are their strengths?*

How did you hear about us?*

Please Specify*