Safe Haven Homes Independent Living Intake Form
Fill out the form below to join our waitlist for independent living housing with Safe Haven Homes. Your information will remain completely confidential.
SAFE HAVEN HOMES QUALIFIED CANDIDATE GUIDELINES & ENROLLMENT PROCESS Who May Be a Good Candidate? Safe Haven Homes is designed for individuals who are able to live independently while benefiting from a safe, stable, and supportive living environment. To be considered for placement, applicants should: • Be able to complete all Activities of Daily Living (ADLs) independently, including bathing, dressing, grooming, toileting, and eating. • Be capable of managing daily routines with minimal assistance. • Be respectful of shared living spaces and house guidelines. • Be able to participate safely within a community living environment. • Have a guaranteed and verifiable source of monthly income. • Be willing to comply with program expectations and policies. Accepted Sources of Income Include: • Private Pay • Social Security Income (SSI) • Social Security Disability Insurance (SSDI) • Veterans Benefits (VA) • Retirement Benefits • Pension Income • Employment Income • Other verifiable sources of recurring income Please Note: Safe Haven Homes is not a nursing facility, assisted living facility, or medical treatment program. Residents must be able to live independently and safely within the home. Applicants must have sufficient income to meet housing costs. ENROLLMENT PROCESS Step 1: Complete the Intake Form Submit the intake form for review. Applications are processed in the order they were received. Step 2: Receive Next Steps Applicants will receive an email regarding eligibility and next steps. Step 3: Complete the Application Qualified applicants will be invited to complete the full application. Step 4: Interview An interview will be scheduled to discuss housing needs, expectations, and program fit. Step 5: Background Check A background screening will be completed as part of the approval process. Step 6: Secure Placement Payment Approved applicants must submit payment to secure placement within the program. Step 7: Schedule Move-In Once all enrollment requirements have been completed, a move-in date will be scheduled. For Referrals and Placement Inquiries: Intake@mysafehomehaven.com
Enrollment Process 1. Complete the Intake Form 2. Receive an Email with Next Steps 3. Complete the Application 4. Participate in an Interview 5. Complete a Background Check 6. Secure Placement Payment 7. Schedule Move-In
Applicants Must
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date Of Birth
Gender
Male
Female
Non-Binary
Other
Marital Status
Single
Married
Divorced
Do you understand this home is for single occupancy only (one resident per bed/lease)?
Yes
No
Are you a veteran ?
Yes
No
Are you requesting housing for anyone other than yourself?
Yes
No
Current living situation
Homeless
With Family/Friends
Shelter
Transitional Housing
Jail/Prison Release
Treatment Center
Other
Current Address( If Applicable)
Refferal Agency/Source
Date Housing Is Needed?
Are you willing to relocate to Lafayette IN for housing?
*
Yes
No
Accepted Sources of Income
Would you be able to provide proof of income?
Yes
No
Monthly Income
Do you understand that housing placement may include a shared room based on availability?
Yes, I understand and accept shared room placement.
No, I am only interested in a private room (subject to availability and additional cost).
Payment Plan for Program Fee
Weekly
Bi-weekly
Monthly
Are you able to live independently without daily assistance?
Yes
No
Do you currently receive help with daily activities( cooking, cleaning ,hygiene ,etc?)
Yes
No
Would you need transportation assistance?
Yes
No
Do you have your own vehicle?
Yes
No
Do you have a valid identification card? (Driver's License, State ID, Passport etc?)
Yes
No
Do you understand that Safe Haven Homes is a shared living residential housing program, and that by entering this housing environment you are agreeing to participate in a structured, supportive setting designed to help you build stability, independence, and healthy routines?
Yes, I Understand
No, I Don't Understand
How do you prefer to be contacted?
Via Text
Via Phone
Via Email
Signature (Confirm accuracy and understanding)
First Name
Last Name
Submit
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