Heartful Living Applicant form

Heartful Living Solutions — Housing Program Application
Income and Payment
What is your primary income source?

Other
Approximate Monthly Income
Is your income verifiable?
How often is it received?
What amount can you afford monthly for housing?
Who will be responsible for payment?
Do you have a housing voucher or rental assistance?
If yes, explain the type and amount.
Do you owe money to a previous landlord or housing program?
If yes, explain.
Thank you for your interest in Heartful Living Solutions! Please complete this application honestly and completely. All information is kept confidential.
Please be aware that Heartful Solutions may also match qualified applicants with trusted partner housing providers when needed to help support faster placement options. By submitting this application, you acknowledge that your housing placement may be offered through Heartful Solutions or one of its partner housing providers, based on availability and program fit.
Applicant Contact Information
Date of Birth
Full Name

First NameLast Name
Gender at Birth
Room Placement Preference, If Applicable
Do you take your medication's regularly
List Current Medications your taking
Housing Needs and Preferences
Phone
Format: (000) 000-0000.
Email
example@example.com
Current Address
Current Living Situation
Preferred Move-In Date

MonthDayYear
Date
How Soon Is Housing Needed?
Preferred Location
City, State
Shared or Private Room Preference
Housing Needs and Timing
Are you willing to accept another available location?
Have you lived in shared housing before?
If yes, describe your experience.
Explain further
Reason for leaving previous residence?
Independent Living Readiness and Support Needs
Are you seeking long-term independent living or short-term transitional housing?
Can You Independently Manage Personal Care (Bathing, Dressing)?
If No, Please Explain Personal Care Supports Needed
Can You Independently Manage Medications?
If No, Please Explain Medication Supports Needed
Can You Independently Manage Mobility (Transfers, Walking)?
If No, Please Explain Mobility Supports Needed
Can You Independently Prepare or Obtain Meals?
If No, Please Explain Meal Supports Needed
Can You Independently Respond to Emergencies or Call for Help?
If No, Please Explain Emergency Supports Needed
Explain Supports Currently Used, If Applicable
Do you have any mental health or substance use treatment needs? If yes, explain
Are you in substance use treatment or relapse? If yes, explain
Willing to comply with house rules and activities?
Are you a U.S Veteran or Service member
Do you receive VA Benefits?
VA Healthcare or Case Management?
Consents and Acknowledgments
Consent to Contact Me About Housing
I Certify That the Information Provided Is True and Accurate to the Best of My Knowledge
Emergency Contact Name, Number, and Relationship
Consent to background checks/eligibility verification?
Acknowledge data usage and storage?
By submitting this application, I consent to receive phone calls, text messages, and voicemail notifications from Heartful Living Solutions and its housing partners regarding housing availability, placement options, application updates, and related services. Message and data rates may apply. Consent is not a condition of purchase. I may reply STOP to opt out of text messages at any time.
Signature
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Heartful Living Solutions — Housing Program Application

Income and Payment

Applicant Contact Information

Housing Needs and Preferences

Housing Needs and Timing

Independent Living Readiness and Support Needs

Consents and Acknowledgments