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. We are not a treatment program, assisted living facility, or personal care home.
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?
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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
Do you currently require assistance with personal care or daily living activities such as bathing, dressing, transferring, medication management, or other daily needs?
*
Yes
No
If yes, please briefly describe the assistance you currently need
*
Type N/A if not applicable
Do you need an accommodation to help you live successfully in the home?
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Yes
No
If yes, please briefly describe the accommodation you are requesting:
*
Type N/A if not applicable
What are your goals while living at Anchor Haven Living?
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Maintain employment
Continue recovery
Improve financial stability
Increase independence
Other
Preferred Move-in Timeline
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Immediately
Within 30 days
Within 60 days
Flexible
Which housing option are you interested in?
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Shared Room
Private Room
Private Bedroom with Private Bathroom
No Preference
Current Housing Situation
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Renting
Staying with family/friends
Transitional housing
Shelter
Homeless
Other
If you have a concern about another resident, are you willing to report it to management rather than confronting, correcting, monitoring, or attempting to enforce house rules yourself? *
*
Yes
No
Monthly Income Source
*
Employment
VA Benefits
SSI/SSDI
Voucher
Program Assistance
No Income
Other
Approximate Monthly Income/Funding Amount
*
Proof of Income/Funding
Browse Files
Please upload one current document showing your income or housing funding, such as a paystub, benefit letter, agency funding, etc. You may also email this document to info@anchorhavenliving.com
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of
Anything you'd like us to know about your housing needs?
I understand that submitting this form does not guarantee approval or reserve a room. Housing is subject to screening, approval, availability, and receipt of required move-in payment.
*
I understand and agree
Submit
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