Cornerstone Kingdom Living Intake Form
Fill out the form below to join our waitlist for independent housing with Cornerstone Kingdom Living. Your information will remain completely confidential.
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Date of birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Marital Status
Single
Married
Divorced
Separated
I understand that this home is for single occupancy only. (One resident bed/lease)
Please Select
Yes
No
Are you requesting housing for anyone other than yourself?
Please Select
Yes
No
Current Living Situation
Homeless
Jail/Prison Release
Shelter
Transitional Housing
Treatment Center
With Family and/or Friends
Other
Current Address
(if applicable)
Monthly Income
Source of Income
Employment
Food Stamps
Family Assistance
SSI/SSDI
Unemployment
Veteran's Benefits
Other
Can you provide proof of income?
Please Select
Yes
No
How often are you paid?
Please Select
Weekly
Bi-Weekly
Monthly
Do you understand that housing is in shared rooms only?
Please Select
Yes
No
I'd like to discuss pricing for a private room
Are you able to live independently without daily assistance?
Please Select
Yes
No
Do you require transportation assistance?
Please Select
Yes
No
Do you have your own vehicle?
Please Select
Yes
No
Do you have a valid ID? (i.e. driver's license, state ID, passport, etc.)
Please Select
Yes
No
Cornerstone Kingdom Living is a shared living program. By entering this housing environment, you agree to participate in a structured supportive setting designed to help you build stability, gain independence and develop healthy routines.
Please Select
Yes, I agree
No, I don't agree
How do you prefer to be contacted?
Please Select
By Email
By Phone Call
By Text
What date is housing needed?
-
Month
-
Day
Year
Date
Referral Agency/Source
By signing, I certify the information I have provided is true.
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