Housing Placement Application
Please complete this form to help us determine the best housing options for your needs.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Availability: when do you need to move in?
*
Email Address
*
example@example.com
What is your current status?
*
Veteran
Senior (age 60+)
Re-entry (formerly incarcerated)
Other
Are you independent or do you need minimal assistance with Activities of Daily Living (ADLs)?
*
Independent (no assistance needed)
Need minimal assistance with ADLs
Which ADLs do you need help with? (Select all that apply)
*
Bathing
Dressing
Grooming
Verbal cue reminders for incontinence
Stand by assistance for showers
Other
What is your total monthly income from all sources?
*
Are you currently enrolled in Medicaid?
*
Yes
No
Do you have a Medicaid Waiver?
*
Yes
No
If yes, which Medicaid Waiver do you have?
How many hours per week are authorized for your Medicaid Waiver?
*
Are you a War-era veteran or Retired veteran
*
Please Select
War-era veteran
Retired veteran
Not service connected veteran
Serve in Military (Honorable or Dishonorable Discharge)
Not-applicable
Are you receiving Aid & Attendance or eligible for this Military benefit?
Branch of Military Service
Army
AirForce
Navy
Marines
Special Forces
Reserves
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Re-entry (formerly incarcerated individuals)
Please Select
Yes
No
Are you on Probation or Parole
Please Select
Yes
No
Do you need stable housing to be released from incarceration?
Please Select
Yes
No
Re-entry support services do you need any of the following?
Please Select
Submit Application
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