Chosen Care Independent Living Application
Apply for Housing With Chosen Care. We’re glad you’re considering Chosen Care as your next step toward stability and independence. To begin the application process, please complete the form below or contact us directly.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
SSN (Social Security Number)
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name:
*
Emergency Contact Phone
*
Please enter a valid phone number.
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Next
Are you applying for Independent Living or Shared Housing?
*
Yes
No
Desired move-in date
*
-
Month
-
Day
Year
Date
Referral Source
*
Self
Agency
Family
Case Manager
Any support needs or background information we should know?
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Financial Information
Monthly Income Source(s)
*
SSI
SSDI
Employment
Other: VA, Vouchers, Waivers
Monthly Income Amount
*
Representative Payee (if applicable)
*
Expected Rent Contributions
Client
Program
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Eligibility Requirements
Are you at least 18 years old?
*
Yes
No
Are you able to live independently?
*
Yes
No
Are you willing to follow home rules?
*
Yes
No
Do you have a valid form of ID?
*
Yes
No
Do you agree to weekly or monthly housing fees?
*
Yes
No
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Behavioral & Safety History
Behavioral Concerns (if any)
*
History of Aggression or Elopement
*
Mental Health Hospitalizations (optional)
Crisis Plan on File
Yes
No
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Legal, Consents & Signatures
Legal Guardian
Yes
No
If yes, please provide Guardian Name:
First Name
Last Name
Guardian's Email
example@example.com
Guardian's Phone Number
Please enter a valid phone number.
Power of Attorney
Yes
No
Program Rules Acknowledgment
I acknowledge that I have reviewed and understand the Independent Living Program rules, including but not limited to house rules, visitor policies, staff access for services, and safety expectations.
*
Consents & Releases
Consent to Receive Services
HIPAA Authorization
Release of Information (Case Manager / Medicaid)
Emergency Medical Consent
Signatures
Applicant Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Guardian Signature (if applicable)
Submit
Should be Empty: