HavenPath Independent Living, LLC

HavenPath Independent Living, LLC
Housing Application Form

Please complete this application to help us determine your eligiblity
Basic Information
1. Applicant Full Name:

First NameLast Name
2. Date of Birth:

MonthDayYear
3. Gender:
4. Race:

Other
5. Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
6. Email Address:
example@example.com
7. Current Address:

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
8. Current Living Situation

Other
9. Do you have any personal identification documents?
10. Current Source of Income
11. What is your monthly income amount (We may ask for confirmation-proof can be shown in person or sent electronically)
12. Do you receive Food Stamps/EBT? (Snap Benefits)
13. Emergency Contact Name:

First NameLast Name
Relationship to Emergency Contact:
e.g., spouse, parent, friend
14. Who referred you to this Housing Program?
(self, case manager, agency name, family member etc.)
Mobility & Physical Limitations
15. Do you have any mobility limitations we should be aware of for housing safety?
16. Do you have the Ability to Live Independently?
Medical and Mental Health
17. Do you have any medical or mental health considerations we should be aware of for safety?
18. Are you currently taking any prescribed medical medications?
19. Do you manage your own medications independently?
20.. Are you recovering from any drug or alcohol addiction?
If yes, are you being treated for it?
21. Are you able to live cooperatively in a shared housing environment without any violent or disruptive behavior?
Background Screening
22. Have you ever been evicted from a previous resident or housing program?
23. Have you ever been convicted of a felony? (sexual, violent, criminal etc)
If yes, please explain
24. Are you a registered sex offender?
If yes, please explain
Lifestyles & House Rules
25. Are you willing to follow house rules (e.g no drugs, no unapproved guest, quiet hours, cleanliness)?
26. Do you smoke?
27. Do you have pets?
28. Is there anything else you'd like us to know?
29. When are you looking to move in?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

HavenPath Independent Living, LLC

Housing Application Form

Basic Information

Mobility & Physical Limitations

Medical and Mental Health

Background Screening

Lifestyles & House Rules