Waitlist Intake Form
Please complete the form below to begin the process. Once submitted, you'll receive a confirmation email with next steps and additional information.
Please List Your First and Last Name
*
First Name
Last Name
Email Address
*
example@example.com
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Race or Ethnicity
*
Please Select
Black/African American
White/Caucasian
American Indian/Native American
Hispanic
Asian
Islander
Gender at Birth
*
Female
Male
Are You Independent? Are you able to live independently, without daily assistance? (You can walk, move around on your own and Do things for yourself?)
*
Yes
No
Do You Smoke?
*
Yes
No
Do You Drink Alcohol?
*
Yes
No
Current Living Situation
*
Living in a Shelter
Living in a Car
Living on the Street
Living in a Hotel
How will you be paying for Housing?
*
SSI
SSDI
VA Benefits
Other
Do you receive food stamps/ EBT? (SNAP BENEFITS)
*
Yes
No
What is your monthly income?
*
Please attach proof of income
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Move-In Date
*
-
Month
-
Day
Year
Date
When was Your last wellness check?
*
-
Month
-
Day
Year
Date
Age
*
Type of Accommodation Preference
*
Private Room
Shared Room
Do you have a mental illness? If none, type "none". If "yes" please explain. (This does not disqualify you; It helps us better place you)
*
If answered yes, please explain what mental health condition you have been diagnosed with?
*
Do you have any other disabilities? If so, please describe
*
Do you require handicap accessibility?
*
Are you a registered sex-offender?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Have you ever been evicted from a previous residence?
*
Yes
No
Are you willing to follow house rules? (e.g., No drugs, No unapproved guest, quiet hours and cleanliness)?
*
Yes
No
For your safety and others, cameras are placed outside and in common areas. Do you feel comfortable with living in a home with cameras?
*
Yes
No
Is there anything else you'd like for us to know? (If not, put N/A)
*
Do you have any pets?
*
Yes
No
How did you hear about Comfort & Courage Independent Living?
*
Website
Phone
Word of Mouth
Flyer/Brochure
Signature for Confirmation
*
Submit
Submit
Should be Empty: