Application

Full Name*

First NameLast Name
Gender*

MaleFemaleTransgenderNon-binary
Race*

CaucasianAfrican AmericanAsianHispanicIslanderAmerican Indian/Native AmericanOther
Date Of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Are we permitted to contact you via text/voicemail on number provided?*

YesNo
Email*
example@example.com
Rep's Organization (ex:The Salvation Army,VA,Hope Atlanta,etc)*
Representative Name*

First NameLast Name
What is the client's desired move-in date?*

MonthDayYear
Current Living Situation*

ShelterVehicleHospital/FacilityHomelessFriend/FamilyIncarceratedShared housing/Group Home
Does the client prefer a private or shared room?*

SharedPrivate
Does the client have a history of mental health condition?*

YesNo
If answered yes, list mental diagnoses
Does the client have a disability?*

YesNo
If answered yes, list disability(s)
Do you take prescription medication? If Yes, are you medication compliant?*

Yes/YesYes/NoNo
Does the client require handicap living accessible living environment ?*

YesNo
Is the client an ex-offender?*

YesNo
Have you been convicted as a sex offender? (Answer does not disqualify you from our program/services)*

YesNo1000 ft restrictionwithout 1000 ft restiction
Are you currently on Probation or Parole? (Answer does not disqualify you from our program/services)*

YesNo
Do you need help with recovering from substance abuse? (ex:opioid(s),alcohol.other drugs, etc) (Answer does not disqualify you from program/services)*

YesNo
Will client have children living with them? (Please list ages)*
How much income do you receive each month?*
How does client intend to pay?*

SSI/SSDI (Preferred)RetirementVAVoucher/Organization FundingEmploymentOther
How did you hear about us

Social MediaReferralWebsiteFriends/FamilyOther
Milestones Independent Living & Functionality Acknowledgment

Our program is designed for individuals who are capable of living independently. We will assist clients with obtaining outside resources; however, you must be able to manage your own:
• Personal hygiene and grooming
• Meal preparation and eating
• Medication (unless managed by an outside provider)
• Mobility and transportation arrangements
• Housekeeping and laundry
• Daily living responsibilities
If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver.
Milestones Independent Living will assist in helping clients obtain outside resources however,this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.*

Understood
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins.*

Agree
I acknowledge that violating rules may result in a strike or dismissal from the program*

Agree
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