LEGACY HAVEN PRIME Waitlist & Pre-screening

LEGACY HAVEN PRIME

WAITLIST & PRE-SCREEN
Name

First NameLast Name
Date of birth:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method:
Are you seeking housing for yourself or someone else?
What type of room are you seeking?
Do you have income or funding that can support the program fees?
If funded by a Caseworker provide contact info:
First Name   Last Name
Agency
Area Code   Phone Number
Email
What is your income or funding source? (Check all that apply)

Other
Monthly income amount:
Are you able to provide proof of income or benefits?
When are you looking to move in?
What is your Veteran Status?
How did you hear about Legacy Haven Prime? (If referred, please list the organization or person.)
Do you understand that this is structured, quiet shared housing for adults? (Not a rehab or medical facility)
Have you lived in shared or structured housing before?
Additional Notes (optional):
Do you have any concerns about shared housing?
By submitting, I understand this places me on the Legacy Haven Prime waitlist and does not guarantee placement.
Signature (E-Signature is OK)
Date

MonthDayYear
Date
Should be Empty: