Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Non-binary
Prefer not to say
Other
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact:
*
Current Living Situation:
*
Homeless
Staying with friends/family
Transitional program
Shelter
Renting
Other
If Other, please specify your current living situation:
How long have you been in your current situation?
*
Reason for needing housing now?
*
Are you a Veteran?
*
Yes
No
Were you formerly incarcerated?
*
Yes
No
If yes, release date:
-
Month
-
Day
Year
Date
Do you have any pending legal issues or court dates?
*
Yes
No
If yes, please explain:
Do you have any physical limitations we should be aware of?
*
Yes
No
If yes, please explain:
Are you able to live independently without 24-hour supervision?
*
Yes
No
Do you take medication on your own without assistance?
*
Yes
No
Do you take mental health medication?
*
Yes
No
If yes, please list the prescription name(s):
Please specify if medication is in pills or shots:
Do you have a TB test result dated 60 days or less, or are you willing to be TB tested?
*
Yes, I have TB test results from the last 60 days
No, but I am willing to be TB tested
No
Do you agree to mandatory drug testing?
*
Yes
No
Do you agree to random room searches?
*
Yes
No
Monthly Income Source:
*
Employment
SSI/SSDI
VA Benefits
Unemployment
Family Assistance
Other
If Other, please specify your income source:
Monthly Income Amount:
*
Are you able to self-pay the monthly program fee of $750?
*
Yes
No
Are you willing to follow a structured environment with rules including:
*
No guests
No food in rooms
Daily hygiene required
Cleaning shared spaces
No drugs, alcohol, or violence
Respectful behavior
Only two clothing storage bins allowed
Applicant Agreement:
*
Yes, I agree to follow all house rules.
No, I do not agree.
Have you ever been convicted of a violent crime?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Any additional details you’d like to share regarding your background?
Do you need help with any of the following?
*
Employment search
Applying for benefits
Transportation
Life skills / goal setting
None
Other
If Other, please specify additional needs:
Desired Move-In Date:
*
-
Month
-
Day
Year
Date
Do you have all required documents (ID, income proof)?
*
Yes
No
Applicant Signature:
*
Date Signed:
*
-
Month
-
Day
Year
Date
Independent Living Intake Registration Form
Please complete this form to apply for our Independent Living program. Your information helps us assess your needs and eligibility.
Should be Empty: