My Residential Journey Boarding Home Housing Waitlist

Boarding Home Housing Waitlist

Complete this form to join My Residential Journey housing waitlist. Submission does not guarantee placement.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Desired Move-in Date*

MonthDayYear
Date
Room Preference*

SharedPrivate
Expected Length of Stay*

30 to 90 days3 to 6 months6 months or longerOther
Current Living Situation
Able to live independently?*

YesNo
Able to manage own medications?*

YesNo
No violent criminal history?*

YesNo
No active substance use*

YesNo
Primary Income Source*

EmploymentSSI or SSDIVeteran benefitsOther
Waitlist Disclosure

** Please note that submitting this form places you on the interest waitlist only. Placement depends on availability, eligibility, and program fit. Submission does not guarantee housing.**
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