• TrueCourse Intake Form

  • Section 1: Personal Information

  • Date of Birth *
     - -
  • Gender *
  • Marital Status *
  • Format: (000) 000-0000.

  • Section 2: Housing & Background

  • What best describes you? (Select all that apply) *
  • What is your current living situation? *
  • Would you be able to provide and verify proof of income? *
  • How do you plan to pay monthly rent? *
  • Can you provide proof of identity? (Valid License or State ID) *
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  • Do you have Insurance *
  • Are you currently working with any case manager,social worker,or re-entry program? *
  • We are currently housing single adults with income. At this time, we cannot house children, couples,or pets. Do you qualify as a single adults? *
  • Are you open to living in a shared housing environment with other? *
  • Are you able to live independently without daily assistance? *
  • Do you have any physical disabilities that require accommodations? *
  • Do you currently take any prescribed medications? *
  • Have you ever been hospitalized for mental health reasons? *
  • Do you have a history of substance abuse? (Select all that apply) *
  • Do you use any tobacco products? *
  • Are you currently on parole or probation? *
  • Are you a registered sex offender?*

  • Section 4: Program Readiness & Anknowledgements

  • Our program is designed for individuals who are highly functioning and capable of living independently. This is not a personal care home,nursing home,or assisted living facility.We do not provide medical care,personal assistance, or supervision. You must be able to manage on your own.

    • Physical and personal hygiene and grooming
    • Meal prep and eating
    • Medication (must be managed by an outside provider)
    • Mobility and tranportation arrangements
    • Housekeeping and laundry
    • Daily living responsibilites 

     If you require medical or personal care services,they must be provided by a licensed outside agency or caregiver arranged and paid for separately.

  • Applicant Declaration

    I certify that the above infomation is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff.

  • Date*
     - -
  • Should be Empty: