• Application

    Please note that this program currently serves Independent single adult women only. We are unable to accommodate children at this time.
  • Race*
  • Format: (000) 000-0000.

  • Housing Needs

  • Current Living Situation*
  • Referral Source*
  • Length of Stay Needed:*
  • Do you have verifiable steady income?*

  • Health & Support Needs

    (This is NOT a medical exam; it helps us determine support level.)
  • Do you have any physical disabilities?*
  • Can you cook your own food?*
  • Do you take any daily medications?*
  • Do you require first-floor housing or have restrictions with stairs?*
  • Do you require assistance with any daily activities?*
  • Do you currently have or need a home health care provider or outside support service?*
  • Will you require any wheelchair-accessible features, mobility assistance, or other accommodations?*
  • Do you have a mental health diagnosis?*
  • Are you connected with any caseworker, therapist, or support agency?*

  • Behavioral & Safety Information

    This helps ensure a safe and stable home for all residents.
  • Any history of Violence or aggression?*
  • Property damage?*
  • Substance use struggles?*
  • Are you willing to follow house rules and shared living expectations?*

  • Background Check (If required by your program)

  • Have you ever been convicted of a felony?*
  • Are you currently on probation or parole?*

  • House Compatibility

  • Are you a registered sex offender?*
  • Are you comfortable living in a shared environment?*
  • Do you smoke?*
  • Do you have allergies?*

  • Documents Needed

    (Attach copies or bring them to the interview.)

  • Applicant Statement

  • I understand that this shared independent living home is intended for single adult women only. At this time, the residence is unable to accommodate children.*
  • I understand and agree that this is a non- medical Independent housing program. I will be responsible for my medical needs and daily tasks. I will not hold the program responsible for services outside the scope of Independent housing.*
  • If selected for the program do you consent to fully comply with all program policies and house rules at all times?*
  • Desired move in date:*
     - -
  • Date*
     - -
  • Should be Empty: