EverHaven Solutions Intake Form

Important Note:

Ever Haven Solutions reviews all submissions as quickly as possible often within the same day.

Completing this form does not guarantee placement. All applicants are reviewed to ensure that our shared housing environment is a good and safe fit for everyone in the homes.

After submission, applicants will complete a brief phone interview to verify the information provided and address any additional questions. Once approved move-in can occur within hours.

Ever Haven Solutions provides shared long -term and transitional housing. Most residents share a bedroom with one other individual. Shared rooms include personal space and privacy dividers. Bathrooms, kitchen, and common areas are shared. Private rooms require more income. Selecting a private room does not guarantee approval. This program is designed for individuals Who are open to shared living as a step forward towards long-term independence. If you are only seeking an apartment or do not wish to share a home/room, this program may not be the right fit at this time.

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Best time to reach you

Gender

Date of Birth

Date

Social Security Number

Please indicate your race/ethnicity (select all that apply)

Do you identify as a member of the LGBTQ+ community?

Emergency Contact Name

Emergency Contact Phone Number

Ever Haven Solutions is an independent living environment. Residents are responsible for daily living tasks including preparing their meals, personal grooming, and general self-care. Are you currently able to walk, prepare your own meals, bathe, dress, and manage your daily needs without hands-on assistance?

If you selected “No” or if you receive any type of assistance now, please describe what support you currently need or receive (for example: reminders, light housekeeping, transportation etc.)

Have you ever been convicted of a crime? Please note, answering yes does not automatically disqualify you.

Do you have any criminal convictions pending? Please note, answering yes does not automatically disqualify you.

City and state of conviction:

If you answered yes to the above questions, please explain:

Are you transitioning from any of the following situations?

Do you currently have a case manager, social worker, or program contact?

If yes, please provide their name and Phone number.

Do you currently or have you ever used any illegal substances?

If yes, please explain.

Do you have any mental illnesses?

If so, has this been diagnosed by a physician?

Are you currently prescribed any medications?

Do you self-administer? Please note, we are not a medical facility and cannot administer medication.

List all medications prescribed to you.

Do you have any allergies (food, medication, environmental, or other)?

List any known allergies.

Which are you applying for?

Are you currently employed?

If employed, how many hours per week?

Employer's name

Employer's address

Pay Frequency

If unemployed, what is your source of income?

How much are your paid/receiving monthly?

Next Pay Date

Date

Do you have identification?

Identification Card

Please upload one or more documents that show how your housing will be paid for. Acceptable examples include: -*Social Security (SSI/SSDI) Award or verification letter *Last 3 paystub’s * Last 3 Bank statements showing regular deposits. *Housing Voucher or Benefit letter. *Sponsorship letter from an Agency, Family, Friend, Organization, or Church. *Program funding or referral documentation

Proof of Income or Financial Support

When are you planning to move?

Please note, there is a $200 one time community fee that will be due to hold your requested bed/room. Rent is due the day of move in and will be prorated if you move in after the 1st of the month. Do you understand and agree?

By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that EverHaven Solutions is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing.

Ever Haven Solutions provides independent shared housing with optional supportive services. Residents must be able to ambulate, bathe, dress, and manage daily life without continuous hands-on care.

While light assistance may be available through our homemaker services, Ever Haven Solutions is not an assisted living or medical facility. Applicants must be capable of independent daily living at the time of placement.

INTAKE FORM