Program Application
Start your journey to independent supportive living. Fill out this application and our program coordinator will contact you within 24-48 hours. Our program is for single people. Currently, our program doesn’t support couples or families with children.
Full Name
*
First Name
Last Name
Date of Birth (Month/Date/Year)
*
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who Referred you? (Social Services, Casemanager, Organiztion, Friend, Family, or Self)
*
Client's Gender
*
Male
Female
Transgender
What type of room are your looking for?
*
Shared Room
Private Room
Private Room with Bathroom
No Preference
When do you need to Move In.
*
Immediately
Within 7 days
Within 2- 4 weeks
No Preference
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)
*
Yes
No
Do you have any physical disabilities or mobility concerns?
*
Yes
No
Are you currently taking any prescribed medications?
*
Yes
No
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)
*
Yes
No
Are you willing to follow the house rules (e.g., No Drugs, No Unapproved Guests, Quiet Hours, Cleanliness)?
*
Yes
No
Have you ever been evicted from a previous residence?
*
Yes
No
Do you Smoke?
*
Yes
No
Do you drink Alcohol?
*
Yes
No
Do you have any pets?
*
Yes
No
Do you have a support team?
*
Family
Friend
Spouse
Sponsor
Caseworker
None
Are you an ex-offender?
*
Yes
No
Have you ever been convicted of a Felony?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
Are you currently on Probation or Parole?
*
Yes
No
Do you received Food Stamps / EBT (SNAP Benefits)?
Yes
No
How do you plan to pay?
*
SSI/SSDI
Retirement
VA Benefits
Job
Voucher
Organization Funding
How much income do you receive monthly? If none please type NONE (this will be verified before move-in)
*
Confirm Income
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If Homeless (how long) & (reason)
Why are you seeking housing at this time?
Is there anything else you would like us to know?
Thank you for your interest in our program. Your information is confidential and will be in contact soon.
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