Clone of Resident Referral Form- K&M Choice Living

Where Independence Meets Choice

Thank you for submitting a client referral.Please complete this form with the available information. Our team will review the referral and reach out regarding next steps based on availability.
Veteran's Housing Application

This application is for U.S. military veterans seeking transitional housing and independent living support (non-medical).
Are you a U.S. Military Veteran?

YesNo
This application is intended for U.S. military veterans.

If you are not a veteran, please complete our Client Housing Application instead.
Who is completing this application?

I am the VeteranCase ManagerSocial WorkerOutreach WorkerOther
Veteran's Full Name*

First NameLast Name
Veteran's Date of Birth *

MonthDayYear
Date
Is the Veteran 18years old or older?*

YesNo
Veteran's Phone Number*
Please enter a valid phone number.
Veteran's Email*
example@example.com
VETERAN'S SERVICE INFORMATION
Branch of Service*
Discharge Status*

HonorableGeneralOther Than HonorableDishonorable
Do you currently receive VA benefits?*

YesNO
Which VA benefits do you currently receive? (Select all that apply)*
Current Living Situation*
Primary Source of Income*
Approximate Monthly Income
Are you able to provide verification of income if requested?

YesNo
Housing Preference?

Shared RoomPrivate RoomNo Preference
What services or support are you seeking? (Select all that apply)
Is the veteran able to manage their medical needs independently?*

YesNo
Are you willing and able to follow house rules and program guidelines?*

YesNo
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Veteran
CONSENT CHECKBOX (IMPORTANT)*

I confirm that I have permission to submit this referral and understand this is a non-medical Independent Living Facility (ILF).
I understand this is a non-medical Independent Living Facility (ILF) and residents must be able to manage their medical needs independently.*

Yes, I understand and AgreeNo, I do not agree
Important Notice
K&M Choice Living is a non-medical Independent Living Facility (ILF).
Submission of this application does not guarantee housing placement.
Housing availability is based on eligibility and space.
Should be Empty:

Where Independence Meets Choice

Veteran's Housing Application

VETERAN'S SERVICE INFORMATION