Detailed Application Form

Supportive Housing Intake Assessment

Join Our Waitlist
Things to Know Before Applying

Thank you for visiting! We’re excited about the opportunity to help you in your journey toward stability and independence.
Our program homes are drug- and alcohol-free environments.

United Living Solutions offers nicely decorated, fully furnished homes with all utilities included — Wi-Fi and laundry are provided at no extra cost.

✅ Guaranteed income required (SSI, SSDI, or organization pay)
✅ Work-ready individuals welcome (Private pay accepted)
✅ Program rules are strictly enforced
Name*

First NameLast Name
Email*
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Best time to reach you*

Hour Minutes

AM/PM Option
Gender*

MaleFemaleOther
Date of Birth**

DayMonthYear
Date
Please indicate your race/ethnicity (select all that apply)
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Have you ever been convicted of a crime?*

YesNo
Do you have any criminal convictions pending?*

YesNo
City and state of conviction*
Explanation if yes*
Transition Situation*

HomelessnessRehabilitationHospital/FacilityShelterIncarcerationOther
Do you currently have a case manager, social worker, or program contact?*

YesNo
If yes, please provide name and contact info
Do you currently or have you ever used any illegal substances?*

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

YesNo
If yes, please specify diagnosis
Are you currently prescribed any medications?*

YesNo
Are you able to self-administer your medications?*

YesNo
Medication reminders
Do you have any physical limitations or accessibility needs?*

YesNo
If yes, please explain
Requested Services

Transportation AssistanceJob PlacementApply for SNAP BenefitsApply for SSI/SSDIOrganizational PayeeHealth Insurance EnrollmentClothing DonationCell Phone/Tablet AssistanceGroup TherapyDay ProgramLife Skills/Recovery Group
Type of room preferred

Shared Room (Starting at $750)Private Room (Starting at $1,000)
Are you currently employed?*

YesNo
Hours per week
Employer's name
Employer's address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pay frequency*
How will client pay?

SSI/SSDIRetirementOrganization FundingJobOther
Monthly income*
Next pay date**

DayMonthYear
Date
Planned Move In Date

MonthDayYear
Date
Please note, there is a $300 one time program fee that will be due to hold your requested 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?*

AgreeDisagree
Application Disclaimer
By completing this form, I understand that the information I provide is voluntary and will be used solely to determine eligibility for housing with United Living Solutions (ULS).
All information submitted is kept confidential and will not be shared, sold, or disclosed to any third party except as required to verify eligibility or as required by law.

Submission of this form does not create a landlord-tenant relationship, nor does it guarantee acceptance, placement, or housing availability.
ULS reserves the right to deny any application that does not meet program criteria or falsifies information.

By submitting this form, I confirm that I have answered all questions truthfully and understand that false or misleading information may result in denial or termination of housing eligibility.
Consent Section

United Living Solutions obtains customer consent for SMS communication through checkboxes, verbal agreements, and other affirmative actions taken by the individual. By submitting a form on our website, providing your phone number, requesting information, or communicating with us, you are giving consent to receive SMS messages related to our services.
By checking this box, I agree to receive text messages about housing availability, intake updates, referral communication, and general service-related information from United Living Solutions at the phone number provided above. SMS frequency may vary. Message and data rates may apply. Text HELP to (839) 218-4835 for assistance. Reply STOP to opt out of receiving SMS messages from United Living Solutions. You will receive no further SMS communication.*

I AgreeI Disagree
Should be Empty:

Supportive Housing Intake Assessment

Consent Section