Break The Cycle Properties Independent Living Intake Form

Break The Cycle Properties Independent Living Intake Form

Fill out the form below to join the waitlist for independent living housing with Freedom Pathways. Your information will remain completely confidential..
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address*
example@example.com
Phone Number (Best Contact)*
Please enter a valid phone number.
Age*
Gender*

FemaleMaleNon-BinaryOther
Martial Status

SingleMarriedDivorced
Do you understand this home is for single occupancy only (one resident per bed/lease)?

YesNo
Current Address (if applicable):

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Living situation:

Homelesswith family/friendsShelterTransitional HousingRe-entryOther
Date of Needed Housing*

MonthDayYear
Date
How did you hear about us (ie: referral agency/source)
Emergency Contact Name*

First NameLast Name
Sources of Income*

SSI/SSDIEmployment/jobUnemploymentSupport from family/friends/ agencies
Will you be able to provide proof of income?*

YesNo
Monthly Income Amount*
Do you take any medications? If yes please list*
Are you able to live independently without daily assistance?*

YesNoNeed assistance with daily living skills
Do you understand that housing is in shared rooms only?*

YesNo/ I would like a private room starting 850.00 monthly
Do you understand that Break The Cycle Properties 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 understandNo, I dont understand
Signature (Confirm accuracy and understanding)

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Confirmation and Acknowledgment

I agree to terms & conditions.
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