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 Break The Cycle Properties. 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.Format: (000) 000-0000.
Age
Gender

Other
Martial Status
Do you understand this home is for single occupancy only (one resident per bed/)?
Current Address (if applicable):

Street Address

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

Other
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
Will you be able to provide proof of income?
Monthly Income Amount
Do you take any medications? If yes please list
Are you able to live independently without daily assistance?
Do you understand that housing is shared and private bedrooms?
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?
Signature (Confirm accuracy and understanding)
Confirmation and Acknowledgment
Should be Empty: