• 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.

  • Thank you for your interest.

    This intake form is the first step in determining whether our structured independent living program is the right fit for you.

    Please answer each question honestly and completely. The information you provide helps us better understand your housing needs and determine eligibility for placement. Submitting this form does not guarantee acceptance into the program.

    After we receive your completed intake form, a member of our team will review it and contact you to discuss the next steps. If it appears you may be a good fit, you'll be invited to complete the full application process.

    Please note:

    Safe Haven Homes serves independent adults who are able to complete all activities of daily living without hands-on assistance.
    A valid photo ID and proof of income or a verified income source will be required before placement.
    Incomplete intake forms may delay the review process.
    We appreciate your interest in Safe Haven Homes and look forward to speaking with you.

  • 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
  • Format: (000) 000-0000.
  • Gender
  • Marital Status
  • Do you understand this home is for single occupancy only (one resident per bed/lease)?
  • Are you a veteran ?
  • Are you requesting housing for anyone other than yourself?
  • Current living situation
  • Are you willing to relocate to Lafayette IN for housing?*
  • Accepted Sources of Income
  • Would you be able to provide proof of income?
  • Do you understand that housing placement may include a shared room based on availability?
  • Payment Plan for Program Fee
  • Are you able to live independently without daily assistance?
  • Do you currently receive help with daily activities( cooking, cleaning ,hygiene ,etc?)
  • Would you need transportation assistance?
  • Do you have your own vehicle?
  • Do you have a valid identification card? (Driver's License, State ID, Passport etc?)
  • 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?
  • How do you prefer to be contacted?
  • Should be Empty: