Help & Haven Independent Living
Fill out the form for our waiting list
Paticipant Name
*
First Name
Last Name
Participant Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Phone Number
*
Gender ( Sex at birth)
*
Male
Female
List Previous Address
*
If homeless , how long have you been without stable housing?
*
Do we have permission to text the phone number provided?
Yes
No
Maybe
What is your current living situation
*
Living in Shelter
Living in a car
Living in a hotel
Living with family or friend
Homeless
Hospital or Facility
Please provide the reason for seeking shared independent living
*
Which best describes you?
*
Veteran
Elderly (able to live independently)
Adult needing affordable housing
Other
Martial Status
*
Married
Single
Divorced
Widowed
Are you currently taking any medication?
*
If so please list
Have you ever been diagnosed with a mental health condition?
*
Yes
No
Prefer not to say
Please describe, if the above question is Yes:
Have you ever been diagnosed with a mental health condition?
Rooming preference: Are you seeking a private or shared room?
*
Private
Shared
No preference
Are you able to perform the following independently? Being independent means being able to take care of yourself and make your own decisions without needing constant help from others. A big part of independence is being able to manage your essential activities of daily living (ADLs). An independent participant can perform most or all of these activities independently. 👉 Please check all that apply.
*
Bathing/Showering
Dressing
Eating
Toileting
Mobility/Transferring (getting in/out of bed or chair)
Medication Management
Cooking/Meal Preparation
Cleaning/Housekeeping
Do you use the following? (Select all that apply)
*
Tobacco / Nicotine Products
Alcohol
Marijuana / Cannabis
Neither
please provide details , if Yes (frequency, type, etc.): __________________________
Do you have a support system
*
Family
Friend
Spouse
Sponsor
Other
Does the participant have any disabilities that we should be aware of?
*
Yes
No
If Yes , please explain_________________________________________________
Does the participant have any mental health history or medical conditions we should be aware of?
*
Yes
No
If yes , please provide detailed list_____________________________________________________
Has the participant ever been to prison, jail, or any correctional facility
*
Yes
No
If you answered Yes, please answer the questions below.
Charge(s): __________________________Date(s): __________________________Explanation / Additional Information: ___________________________________________
Are you currently on parole?
*
Yes
No
If Yes, Please provide parole officer contact information
Is the participant currently registered, or have they ever been required to register, as a sex offender?
*
Yes
No
Back
Next
Please List your emergency contact information
*
(name, number, relationship to you)
Does the participant require handicap accessibility?
*
Yes
No
Maybe
How will the participant pay for housing?
*
SSI/SSDI
Retirement
Private Pay
Employed
Penison
Other consistent income source
Back
Next
File Upload
Browse Files
Drag and drop files here
Choose a file
Proof of Income is required
Cancel
of
If accepted, when will you be ready to move in
*
-
Month
-
Day
Year
anticipated move-in date
Tell Us About Yourself:
Please provide a brief description of yourself, including your background, interests, goals, or anything you would like us to know.(Optional: You may include your hobbies or personal strengths.)
Referral Source
How did you hear about Help & Haven Independent Living?
⚠️ Program Disclaimer: We do not provide medical care or assistance with daily living activities (such as bathing, dressing, grooming, eating, toileting, or mobility). All program participants must be able to live independently.
*
I Understand
⚠️ Medication Disclaimer: Participants are responsible for managing and taking their own medications. Staff do not provide, store, or assist with medication in any way.
*
I Understand
Signature
*
Continue
Continue
Should be Empty: