Sincere Kennedy Haven Independent Living Intake Form
Fill out the form below to join the waitlist for independent living housing with sincere Kennedy Haven. Your information will remain completely confidential.
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Female
Male
Phone Number
*
Email Address
Current Living Situation
Homeless
With Family/Friends
Shelter
Hospital Facility
Other
Do you have any medical conditions we should be aware of ?
*
Yes
No
Have you lived in an independent or group home before?
Yes
No
Do you have any mental health diagnoses?
*
Yes
No
Are you currently under a doctors or therapist care?
*
Yes
No
Are you taking any prescribed medications?
*
Yes
No
If so are you able to self administer ?
*
Yes
No
Daily living skills (Please check all that Apply)
*
Able to cook simple meals
Able to clean personal space
Manages personal hygiene independently
Manages medication independently
Uses public transportation
Manages money/budgeting
Needs some assistance with some daily task
Source(s) of income (Check all that apply)
*
Employment
SSI/SSDI
Veteran benefits
Food Stamps
Unemployment
Family Help
Other
Would you be able to provide proof of income ?
*
Yes
No
Monthly Income ($)
Do you have a valid identification card ? (Driver License, State ID, Passport, etc)
*
Yes
No
Do you understand that Sincere Kennedy Haven is a shared living 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
Signature (confirm accuracy and understanding)
*
Submit
Submit
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