Intake Form

New Light Commons Independent Living Intake form

Complete the form below to reserve your place on the waitlist for independent living housing with New Light Commons. All information you provide is kept private and handled with the utmost confidentiality
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number (Best Contact)
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Gender
Marital Status
Do you understand this program is for single occupancy only (one resident per bed)?
Are you applying for housing for anyone other than yourself?
What is your current living situation?
Current Address (if applicable)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referral Agency/Source
Date Housing is Needed

MonthDayYear
Date
Source(s) of Income
Are you able to provide proof of income?
What is your monthly income ($)
Program fee payment option
Are you able to live independently without daily assistance?
Do you understand that housing is in shared rooms only?
Do you currently receive help with daily activities(cleaning,cooking,hygiene,etc.) ?
Would you need transportation assistance?
Do you have your own vehicle?
Do you have a valid identification card? (Drivers License,State ID,Passport etc;)
By joining New Light Commons, you understand that this is a shared living program. Entering this housing environment means you agree to take part in a structured and supportive community designed to help you build stability, independence, and healthy daily routines.
Signature

First NameLast Name
Confirmation and Acknowledgment
Should be Empty:

New Light Commons Independent Living Intake form