Mae’s Loving Arms, LLC Independent Living Intake Form
Fill out the form below to join the waitinglist for Independent living housing with Mae's Loving Arms. Your information will remain completely confidential. Contact us if you have any questions: 901-356-8075
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Male
Female
Non-Binary
Other
Marital Status
*
Single
Married
Divorced
Do you understand that this home is for single occupancy only (one resident per bed/lease)?
*
Yes
No
Are you requesting housing for anyone other than yourself?
*
Yes
No
Current Living Situation
*
Homeless/Shelter
Staying with family/friend
Hospital/Treatment Facility
Jail/Prison Release
Treatment Center
Other
Referral Agency/Source
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Housing is Needed
*
-
Month
-
Day
Year
Date
Proof of Income
Income & Employment Information
*
SSI/SSDI
Food Stamps
Employment
Veterans Benefits
Unemployment
Family Help
Would you be able to provide proof of income?
*
Yes
No
Monthly Income($)
*
Employment/Income Proof
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Employment Letter, Two Months Pay Stubs, etc.
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of
Payment Plan for Rent?
*
Weekly
Bi-weekly
Monthly
Are you able to pay a one-time $250, non-refundable deposit?
*
Yes
No
Are you able to live independently without daily assistance?
*
Yes
No
Do you understand that housing is in a shared room only?
*
Yes
No
Do you currently receive any help with daily activities (such as cooking, cleaning, hygiene, etc.)?
*
Yes
No
Would you need transportation assistance?
*
Yes
No
Do you have your own vehicle?
*
Yes
No
Do you have a vaild identification card (ID, Passport, or Driver Licensed)?
*
Yes
No
ID or Driver license:
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of
Criminal History (Confidential):
Have you been convicted of a felony? If yes, please briefly explain:
Are you currently on probation or parole?
Yes
No
Do you understand that Mae’s Loving Arms is a shared independent living housing environment, and that by entering this independent living housing you are agreeing to participate in a structured, supportive setting designed to help you build stability, independence, and healthy routines?
*
Yes
No
How do you prefer to be contacted?
*
Via text
Via Phone
Signature
*
Continue
Continue
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