EverHaven Solutions Intake Form

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.
Best time to reach you

MorningAfternoonEvening
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security Number*
Please indicate your race/ethnicity (select all that apply)

American Indian or Alaska NativeAsianAfrican AmericanWhite (Caucasian)Hispanic or Latino/aNative Hawaiian or Other Pacific IslanderPrefer not to answerOther
Do you identify as a member of the LGBTQ+ community?

YesNo
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?

Yes (I am independent)No (no I need 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.*

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

YesNo
City and state of conviction:
If you answered yes to the above questions, please explain:
Are you transitioning from any of the following situations?

RehabilitationHomelessnessSubstance Abuse RecoveryRecently IncarceratedDomestic Violence ShelterMental health Facility
Do you currently have a case manager, social worker, or program contact?*

YesNo
If yes, please provide their name and Phone number.
Do you currently or have you ever used any illegal substances?*

YesNo
If yes, please explain.
Do you have any mental illnesses?*

YesNo
If so, has this been diagnosed by a physician?*

YesNo
Are you currently prescribed any medications?*

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

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

YesNo
List any known allergies.
Which are you applying for?*

Shared Room (starting at $750)Private Room (starting at $1,300)
Are you currently employed?*

YesNo
If employed, how many hours per week?
Employer's name
Employer's address
Pay Frequency*

WeeklyBiweeklyMonthlyOtherN/A
If unemployed, what is your source of income?
How much are your paid/receiving monthly?*
Next Pay Date*

MonthDayYear
Date
Do you have identification?

YesNo
Identification Card*

Cancelof
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
Cancelof
When are you planning to move?*

ImmediatelyWithin 1-2 weeksWithin 2-4 weeksLater than one month
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?*

YesNo
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.*

YesNo
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.
Should be Empty:

INTAKE FORM