Participant Intake & Enrollment Application

Yes No
SSI SSDI Employment Other:
Monthly Income Amount (if any): $
Housing Preferences or Needs
Any disabilities or accommodations needed? Yes No If yes, explain:
Shared RoomPrivate Room (if available)
Independent Living & Functionality Acknowledgment
Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision. You must be able to manage your own:
- Personal hygiene and grooming
- Meal preparation and eating
- Medication (unless managed by an outside provider)
- Mobility and transportation arrangements
- Housekeeping and laundry
- Daily living responsibilities
If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.
Yes
No - Please explain:
Yes - Agency Name (if applicable):
No
I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing.
Participant Initials:
Date:

MonthDayYear
Date
Program Disclosure
House of Peace & Provisions
pg. 3

House of Peace & Provisions is a voluntary, independent shared living program. Participation in this program does not create a landlord-tenant relationship, lease, or right to permanent housing. The program does not provide medical care, therapy, case management, or assisted living services. Participation is month-to-month and contingent upon eligibility, availability, and compliance with program rules.
Independent Living Acknowledgment
Please initial each statement:
I am able to manage my own daily living activities without assistance.
I understand this program does not provide medical or personal care services.
I agree to follow all program rules and community standards if accepted.
Program Agreement Preview
I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins. I acknowledge that violating rules may result in a strike or dismissal from the program.
Applicant Declaration
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submission of this application does not guarantee placement.
Participant Name:
Participant Signature:

Clear
Date:

MonthDayYear
Date
Staff Name:
Signature:

Clear
Date:

MonthDayYear
Date
House of Peace & Provisions
pg. 4
Should be Empty: