Information Request
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Government Issued ID Type
*
Please Select
Drivers Licenses
State ID Card
U.S. Passport
Military ID
Permanent Resident Card
Upload ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Last 4 Digits of SSN
*
Are you a veteran?
Yes
No
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Caseworker Information
Are you currently working with a caseworker?
*
Yes
No
Caseworker Name
Agency/Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Housing Background
Are you currently experiencing homelessness?
*
Yes
No
If yes, how long have you been homeless?
Have you previously lived in shared housing?
*
Yes
No
If yes, how long and what is your reason for leaving?
Are you comfortable sharing a bedroom with another individual?
*
Yes
No
What area would you prefer to be in?
*
Are you willing to relocate?
*
Yes
No
Independent Living & Functional Ability
Please check all that apply:
*
I am able to care for myself independently
I can bathe, dress and feed myself
I can manage my own medications
I do not require daily supervision
I am able to live safely in a shared housing environment
Mental Health & Independence Disclosure
Do you currently have a mental health diagnosis?
*
Yes
No
If yes, please specify:
Are you currently taking any medications? (Over-The-Counter or Prescribed)
*
Yes
No
If yes, please include ALL names of medications:
Are you able to live independently without assistance?
*
Yes
No
If no, what assistance would be needed?
Do you require assistance with daily living activities?
*
Yes
No
If yes, please explain (for housing placement purposes only):
Do you have any food allergies?
*
Yes
No
If yes, please list ALL allergies:
Income Information
What is your primary source of income?
*
Employment
SSI/SSDI
VA Benefits
Retirement
Other
What is your approximate monthly income?
*
Background Disclosure
Have you been convicted of a violent offense within the past 5 years?
*
Yes
No
If yes, please explain:
Program Expectations Acknowledgement
By checking these boxes below, I acknowledge and understand:
*
This is an independent living home program
This is NOT assisted living or medical care
I must be able to care for myself
I must follow all house rules
Monthly program fees are required
There is a ZERO tolerance policy for alcohol and substance use/abuse
Failure to follow rules may result in discharge
Signature
*
Continue
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