Luxe Haven Membership Assessment
Please ensure the application is completed in full. Incomplete submissions will not be considered for program membership.
Date
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-
Month
-
Day
Year
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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Current Address
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I do not currently have an address where I reside.
Date of Birth
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-
Month
-
Day
Year
Gender
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Female
Male
Martial Status
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Single
Married
Separated
Divorced
Emergency Contact Name
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Emergency Contact Phone Number
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Please describe your present living situation. How long have you been there?
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If you are in transition, please let us know which of the following best reflects your situation.
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Rehabilitation
Homelessness
Substance Abuse Recovery
Domestic Violence Shelter
Mental Health Facility
Recently Incarcerated
Senior Living Facility
Eviction
Other
If you answered 'Other', please provide details below:
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If not applicable, please enter 'N/A'.
Do you currently have a case manager, social worker, or program contact?
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Yes
No
If 'Yes", please provide their name and contact info.
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If not applicable, please enter 'N/A'.
Are you receiving support from any community agencies? If yes, please list them below, including name and contact info.
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If not applicable, please enter 'N/A'.
Are you currently employed?
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Yes
No, but I'm seeking employment.
No, but I still have a source of income.
Do you have a reliable source of income to cover the one time program fee, monthly room charges, and your personal expenses each month?
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Yes
No
Income Source
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SSI/SSDI
VA Disability
3rd Party Organization Payments
Job/Paycheck
Sponsor/Gift/Allowance
Other
If you answered 'Other', please provide details below:
*
If not applicable, please enter 'N/A'.
Do you have a secondary source of income?
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Yes
No
If 'Yes', please provide details below:
*
If not applicable, please enter 'N/A'.
Total Monthly Income Amount
*
Payee Name (If Applicable)
First Name
Last Name
Are you a veteran?
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Yes
No
How soon are you planning to move?
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Immediately
Within 1-2 weeks
Within 2-4 weeks
Will you be the only person participating in the program or will there be someone else accompanying you?
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Yes, I will be the only person.
No, someone will accompany me.
We offer co-ed (men & women), women-only, and men-only residences. Which setting are you most comfortable with?
Women only
Men only
Co-ed (men and women) or whichever is available for immediate move in
Do you have or plan to bring any pet(s) with you?
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Yes
No
Do you require any daily assistance with personal care? (i.e. bathing, dressing, medication management, or mobility)
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No, I'm completely independent.
Yes, I require minimal assistance.
Yes, I require complete daily assistance.
If you are prescribed medications, do you take them independently? Please note: Luxe Haven is not a medical facility and cannot administer medication.
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I take my medications independently.
I take my medications but require assistance.
I do not take any medications.
Do you have any physical limitations or accessibility needs, or require medical supervision or specialized services to live safely day to day?
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Yes
No
If 'Yes', please describe:
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If not applicable, please enter 'N/A'.
How many hospitalizations have you had in the past 3 months?
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If not applicable, please enter 'N/A'.
Are you able to independently manage daily tasks like your meals, laundry, and cleaning of your living space without onsite staff support?
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Yes, I am completely independent.
No, I require assistance.
This program is designed for independent adults only. It is not an assisted living, group home, or medical housing program. Do you acknowledge and understand this requirement?
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Yes
No
Are you comfortable living in a shared home community where common areas such as the kitchen, bathroom, living and laundry rooms, are used by other members in the residence?
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Yes
No
Are you comfortable sharing a semi-private bedroom with at least one other resident?
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Yes, I'm just looking for affordable, safe, functional housing.
No
Have you previously lived in shared housing? If yes, please describe your experience.
*
If not applicable, please enter 'N/A'.
Do you agree to follow all program rules, including quiet hours, visitor policies, and cleanliness standards?
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Yes
No
Have you ever been asked to leave a residence due to behavior, rule violations, or disturbances?
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Yes
No
If 'Yes', please explain:
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If not applicable, please enter 'N/A',
How do you typically handle disagreements with roommates or neighbors?
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To ensure we place you in the most suitable unit, are you able to safely and comfortably use stairs to reach bedrooms on the second floor?
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Yes
No
Have you ever been diagnosed with a mental health condition or received treatment for one?
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Yes
No
If 'Yes', please advise of the diagnosis/treatment. (Please note, answering doesn't disqualify you, it helps us understand any support or accommodations you may need.)
*
If not applicable, please enter 'N/A'.
Have you had frequent 911 calls related to personal mental health crises? Please note, answering 'Yes' does not disqualify you.
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Yes
No
Have you ever been convicted of a violent crime or property damage? Please note, answering 'Yes' does not automatically disqualify you.
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Yes
No
Have you ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify you.
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Yes
No
Do you have any pending criminal or sexual convictions pending? Please note, answering 'Yes' does not automatically disqualify you.
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Yes
No
City and State of conviction(s)
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If not applicable, please enter 'N/A'.
If applicable, provide details of past or pending convictions.
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If not applicable, please enter 'N/A'.
Are you currently on probation or parole?
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Yes, I'm on probation.
Yes, I'm on parole.
No, I'm not on either.
If you answered 'Yes' to probation or parole, provide condition details.
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If not applicable, please enter 'N/A'.
Do you currently use any substances, such as drugs or alcohol? If yes, please specify your substance of choice.
*
If not applicable, please enter 'N/A'.
Our residences are alcohol and drug free (including marijuana). Are you able to comply with this requirement?
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Yes
No
Proof of Income
*
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*Acceptable proof of income to be uploaded: Most current (4) consecutive paystubs; Social Security Award, Pension, VA Benefits, Unemployment, Disability or Assistance Award Letters; 2 most recent bank statements reflecting benefit deposits or a 1099 form. All documents must show details of your name, benefit type, and monthly amount. Invalid documents will lead to automatic disqualification.
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Proof of Valid ID
*
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*State-issued Driver's License/ID Card; Real ID; U.S. Passport or Passport Card; U.S. Permanent Resident Card; Military ID Card; Veteran Health Identification Card (VHIC) - to be accompanied by a standard photo ID; Veteran ID Card (VIC); State Veteran ID Cards; Tribal Identification Card
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What are 3 goals you are aiming to accomplish while in our program?
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How did you find out about us?
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