Housing Participant Information Request Form
Thank you for your interest. Parkway Grove Shared Living provides furnished shared housing for adults seeking stable, independent living in a respectful, drug and alcohol-free environment. Residents enjoy private bedrooms within a shared home and share common areas such as the kitchen, bathroom, and living spaces. This home is best suited for individuals who are able to live independently and maintain a peaceful, cooperative living environment with other residents. Completion of this form allows our team to review whether Parkway Grove may be a good fit for your housing needs. Submission of this form does not guarantee housing placement, as availability and shared housing compatibility must be considered.
Your Name:
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First Name
Last Name
Your Phone Number:
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-
Area Code
Phone Number
Your E-mail:
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example@example.com
Are you a:
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Senior in need of housing
Family/Friend assisting with housing efforts
Professional assisting with housing efforts (See Referral Intake Form)
Preferred method of contact:
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Phone
Text
Email
Name of person in need of housing options if different from above:
First Name
Last Name
Phone Number:
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Area Code
Phone Number
E-mail (Optional):
example@example.com
Current City & State
Housing Needs
Which type of housing are you seeking?
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Private furnished bedroom in shared home
Short-term transitional housing
Longer-term shared housing
Desired move-in timeframe:
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Immediate
Within 30 days
Within 60 days
Flexible
How long do you expect to stay?
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1–3 months
3–6 months
6–12 months
Longer term
Current Housing Situation
What best describes your current housing situation?
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Renting an apartment or house
Living with family/friends
Staying in a hotel
Transitional housing or shared housing
Currently without stable housing
Other
Have you previously lived in a shared community?
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Yes
No
Reason for seeking housing
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Employment & Income
Current employment status:
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Full-time employment
Part-time employment
Self-employed
Retired
Disability income
Other
How will you pay for housing?
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Employment income
SSI / SSDI
Self-employed
Retirement income
Disability income
Organization assistance
Other
Monthly income range (approximate):
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Under $1,200
$1,200–$2,000
$2,000–$3,000
$3,000+
Do you receive SNAP/EBT benefits?
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Yes
No
Shared Living Compatibility
Because this is a shared living home, we ask a few questions to ensure a good fit.
Are you comfortable sharing common areas such as kitchen, bathroom, and living spaces with other residents?
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Yes
No
Have you lived in shared housing with roommates before?
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Yes
No
Are you willing to follow shared house guidelines including quiet hours and respectful behavior toward other residents?
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Yes
No
Are you comfortable living in a home with 24-hour security cameras in common and exterior areas?
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Yes
No
Do you have pets?
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Yes
No
Do you? (Select all that apply)
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Smoke
Drink Alchol
Occaisonally do other substances
None - I am sober
None of the above
Independence Level
This home is designed for individuals who are independent in their daily living. However, support services may be available through First Choice Personal Care & Living Solutions if eligible.
Do you require assistance with daily activities?
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No assistance needed
Occasional support
Regular assistance
Do you take any medications you manage on your own?
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Yes
No
Do you have a support system? (Select all that apply)
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Family
Case Manager
Other
Background & References
Do you have a criminal history or currently dealing with legal issues?
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Yes
No
Are you a registered Sex Offender?
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Yes
No
If yes, reason for eviction:
Additional Information
Is there anything you would like us to know about your housing needs? Please include what is most important to you in a shared living environment?
How did you hear about us:
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By submitting this form, I understand: This is a preliminary screening form and does not guarantee housing placement. Applicants may be contacted for additional information or a brief phone conversation. Additional documentation may be required before move-in.
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I agree
Signature
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