Applicant Information Form
Please complete all sections to provide a comprehensive overview for your application.
Applicant Information
Tell us about yourself.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Preferred Move-In Date
-
Month
-
Day
Year
Date
Current Housing Status
Please select your current housing situation.
What is your current housing status?
*
Living with Family/Friends
Homeless
Other
Financial & Income Assessment
Tell us about your financial and income situation.
Primary Source(s) of Income (Select all that apply)
*
Social Security Retirement
Social Security Disability (SSDI)
Supplemental Security Income (SSI)
Pension
Employment Income
Veteran’s Benefits
Section 8 / Housing Voucher
Family Support
Other
Is your income stable?
*
Yes
No
Are you able to pay rent consistently?
*
Yes
No
Have you ever been evicted?
*
Yes
No
If yes, please explain the circumstances of your eviction.
Independence & Daily Living
Please tell us about your ability to perform daily tasks.
For each daily activity, indicate if you can perform it independently.
*
Yes
No
Bathing
Dressing
Toileting
Feeding yourself
Walking or transferring
Managing personal hygiene
Do you need hands-on help with any daily activities?
*
Yes
No
Medication & Health
Share your medication and health needs.
Are you able to manage your medications independently?
*
Yes
No
Medication needs (Select all that apply)
Medication reminders
Medication administration
Injections or medical monitoring
Medical device usage (Select all that apply)
Oxygen
Catheter
Feeding tube
Mobility device (walker/cane)
Functional Assessment
Help us understand your functional needs.
Diagnoses (Select all that apply)
Dementia or Alzheimer’s
Severe mental illness requiring supervision
Substance use disorder (active)
Other
Behavioral issues (Select all that apply)
Wandering
Aggression or violent behavior
Frequent confusion or disorientation
Abilities (Select all that apply)
Follow house rules
Communicate needs clearly
Live cooperatively with others
Lifestyle Compatibility
Tell us about your lifestyle preferences.
Do you smoke?
*
Yes
No
How often do you use alcohol?
*
None
Occasional
Regular
Are you comfortable with shared living arrangements?
*
Yes
No
Do you have pets?
Yes
No
Safety & Legal
Please answer the following safety and legal questions.
Do you have a history of any of the following? (Select all that apply)
Violence
Arson
Sexual offenses
Are you currently on probation or parole?
Yes
No
If yes, please explain your probation/parole status.
Applicant Acknowledgment
Please read and acknowledge the statement below.
I acknowledge that the information provided is accurate and complete to the best of my knowledge. I understand that providing false information may affect my eligibility.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
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