Lovebird Ecosystem Application
(Housing • Care • Community • Partnerships)
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Applicant Information
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact
*
Phone
Email
Text Message
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Application Type
What are your applying for?
*
Shared Living / Housing (Nest Homes)
In-Home Care Services
Community Programs
Referral (Professional / Agency)
Partnership / Collaboration
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Household Information
Who is this application for?
*
Myself
Family Member
Client
Number of People in Household
Please Select
1
2
3
4
5
6+
Desired Move-In / Start Date
-
Month
-
Day
Year
Date
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Funding & Coverage Information
Primary Funding Source
*
Please Select
Private Pay
Medicaid / Waiver Program
Veterans Administration (VA)
Grant-Funded Program
Unsure / Need Assistance
Secondary Funding Source (Optional)
Please Select
Private Pay
Medicaid / Waiver Program
Veterans Administration (VA)
Grant-Funded Program
Unsure / Need Assistance
Do you currently have a case manager?
*
Yes
No
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Housing Details (Nest Homes)
Preferred Location
Expected Length of Stay
*
Short-Term
Long-Term
Transitional
Housing Considerations or Notes
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Care Services Information
Type of Support Needed
*
Personal Care
Companionship
Homemaking
Estimated Hours Needed Per Week
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Referral Information
How did you hear about us?
Please Select
Hospital / Facility
Case Manager
Community Partner
Website / Social Media
Word of Mouth
Referring Organization (if applicable)
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Supporting Documents
Upload Documents (Optional)
Browse Files
Drag and drop files here
Choose a file
Max of 2-3 Files: Insurance Card / Award Letters / Referral Documents
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of
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Acknowledgment & Consent
Acknowledgment Checkbox (Required)
*
I understand that submitting this application does not guarantee services, housing, or placement.
I understand eligibility is subject to availability, funding, and program guidelines.
I understand that additional documentation may be required.
HIPAA-Safe Disclaimer
Information submitted is used solely for screening, coordination, and eligibility review. Submission does not establish a client-provider relationship or guarantee services.
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Typed Signature (Applicant's Full Legal Name)
Submission Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: