Independent Living Program Application

Independent Living Program Application
Full Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Preferred Name
Date of Birth*

MonthDayYear
Date
Age*
Gender

MaleFemaleNon-binaryPrefer not to sayOther
Social Security Number (last 4 digits)*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City*
State*
ZIP Code*
Length of Time at Current Address*
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email Address*
example@example.com
Eligibility Information
Are you 18 years of age or older?*

YesNo
Are you legally able to live independently?*

YesNo
Are you currently employed?*

YesNo
If yes, Employer Name and Position
Are you currently enrolled in school or job training?*

YesNo
Do you currently receive public assistance (e.g., SSI, SSDI, SNAP)?*

YesNo
If yes, please specify
Housing Status
Current Housing Situation*

HomelessAt risk of homelessnessLiving with family/friendsTransitional housingOther
Reason for seeking independent living support*
Independent Living Skills Assessment
Select the skills you want to improve*

Budgeting & financial literacyEmployment readinessEducation supportLife skills (cooking, cleaning, time management)Mental health or wellness supportTransportationCommunity resources & benefits navigationConflict resolution & communication skillsOther
Health & Support Services (Confidential)
Do you have any physical, mental, or emotional conditions that may affect your participation?*

YesNo
If yes, please describe (optional)
Do you require accommodations to fully participate in the program?*

YesNo
If yes, please explain
Legal & Safety Information
Are you currently on probation or parole?*

YesNo
Do you have any pending legal matters?*

YesNo
Are there any restraining or protective orders we should be aware of for safety planning?*

YesNo
Goals Statement*
Program Commitment
Are you willing to actively participate in program requirements?*

YesNo
Are you willing to comply with program rules and policies?*

YesNo
Applicant Certification
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Staff Use Only
Application Received By
Date Received

MonthDayYear
Date
Eligibility Determination

ApprovedWaitlistedDenied
Notes
Should be Empty:

Independent Living Program Application

Emergency Contact

Eligibility Information

Housing Status

Independent Living Skills Assessment

Health & Support Services (Confidential)

Legal & Safety Information

Program Commitment

Applicant Certification

Staff Use Only