Language
English (US)
Spanish (Latin America)
Form
Waiting List Registration
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Income and Benefits
Do You Have A Steady Source of Income?
Yes
No
What Is Your Main Source Of Income?
SSI
SSDI
VA Benefits
Employment
Other
If Other, Write Here
What Is Your Estimated Monthly Income?
Do You Receive Food Stamps/ EBT (SNAP Benefits)
Yes
No
Activities of Daily Living Assessment Form
How independent are you in moving around by yourself?
Very independent/ no assistance needed
Uses walker or cane but can do it on my own.
Need total help from someone to help me move around.
How independent are you in dressing yourself?
Very independent/ no assistance needed
Needs light assistance with dressing
Need total help from someone to help me get dressed
How independent are you at bathing yourself?
Very independent/ no assistance needed
Needs to be reminded but can do it without assistance
Need total help from someone to bathe me
How independent are you with going to the bathroom on your own?
Very independent/ no assistance needed
Uses walker or cane but can do it on my own.
Incontinent/needs total help for restroom care
How independent are you with eating on your own?
Very independent/ no assistance needed
Needs food set up but can feed self.
Needs total assistance being fed
Are You Currently Taking Any Prescribed Medications?
Yes.
No.
Do You Have Difficulty Accessing Your Medications( Cost, Transportation, Insurance, Etc.)
Yes.
No.
If yes, please explain.
Do You Have Any Physical Disabilities or Mobility Concerns?
Housing Preferences/ Needs
When Do You Need Housing? (Move In Date)
What Type Of Room Are You Looking For?
Shared Room
Private Room
No Preference
Have You Ever Been Evicted From A Previous Residence?
Yes
No.
Have You Ever Been Convicted Of a Felony?
Yes.
No.
Are You A Registered Sex Offender?
Yes.
No.
Are You Willing To Follow House Rules ( No Drugs, No Unapproved Guests, Quiet Hours and Cleanliness)
Yes
No
Do You Smoke?
Yes
No
Do You Have Any Pets?
Yes.
No.
Why Are You Seeking Housing At This Time?
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: