Housing Interest & Pre-Screening Form
Thank you for interest in Anchor Haven Living. IMPORTANT: Anchor Haven Living is an adult shared housing program. We cannot accommodate families or minor children residing in the home. We are not an emergency shelter.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
example@example.com
Anchor Haven Living is a shared housing environment where residents have a private or shared bedroom and share common areas such as the kitchen, living room, and laundry room. Are you comfortable with this arrangement?
*
Yes
No
Are you a Veteran?
*
Yes
No
Do you require assistance with any activities of daily living (bathing, dressing, transferring, medication management, etc.)?
*
Yes
No
Are you currently working with a case manager or referral program?
*
Yes
No
If yes Agency/ Organization name
Case Manager name phone and/or email address
What are your goals while living at Anchor Haven Living?
*
Maintain employment
Continue recovery
Improve financial stability
Increase independence
Other
Preferred Move-in Timeline
*
Immediately
Within 30 days
Within 60 days
Flexible
Which housing option are you interested in?
*
Shared Room
Private Room
Either
Current Housing Situation
*
Renting
Staying with family/friends
Transitional housing
Shelter
Homeless
Other
Monthly Income Source
*
Employment
VA Benefits
Disability
Voucher
Program Assistance
No Income
Other
Anything you'd like us to know about your housing needs?
Submit
Should be Empty: