Independent Living Waitlist Form
1. Applicants Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Who is filling out this application?
Self
Guardian
Case Manager
Other
2. Application Details
Current living situation:
Hospital Discharge Pending
Homeless
Staying with Family
Other (Explain)
How soon do you need housing?
Within 72 hours
Within 1-2 weeks
Next 30 days
Housing Preference
Shared Room ($750/month)
Private Room ($900/month)
Either
3. Support Needs
Are you able to care for yourself independently?
Yes
No
Are you currently sober?
Yes
No
Do you have any history of violence?
Yes
No
Do you currently have income or financial support?
Yes
No
Services of Interest
Safe housing
Life skills coaching
Job readiness support
Budgeting
Case Management
Social/community support
What is your #1 goal in the next 30 days?
Emergency Contact Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I understand Covan Haven Supportive Housing is private-pay, non-medical, and I will be placed on the waitlist for the next available opening.
Notes/Comments
Submit
Should be Empty: