Housing Member Intake Form
Please complete this form to apply for our housing program. All information is kept confidential.
Applicant Full Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sober Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last four of Social Security number
Marital status
Single
Married
Divorced
Widowed
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What is your gender at birth?
*
Male
Female
Do you receive food stamps?
Yes
No
Do you have a vehicle?
Yes
No
Can you independently prepare your own meals?
Yes
No
Have you lived in a co-independent setting before?
Yes
No
Can you independently get out of bed, go up and down the stairs and dress yourself?
Yes
No
Are you currently with a home health company to receive ADL's?
Yes
No
Do you occasionally hear voices, knocking on doors or walls?
Yes
No
Are you financially able to pay your rent starting at $730 shared room to $1,030 private room per month plus a onetime $250 nonrefundable program cleaning fee?
Yes
No
Do you smoke or vape?
Yes
No
Are you willing to follow the program rules?
Yes
No
Are you a registered sex offender?
*
Yes
No
Do you have a history of violence, substance abuse, or elopement?
Yes
No
If yes, please explain
Are you currently working with an organization to receive case management services?
Yes
No
If so, please list name of the organization, caseworker name and phone number?
Are you on parole or probation?
*
Yes
No
If so, please provide your parole/probation officer name and phone number:
Have you been incarcerated if so, what was the reason?
Do you have a mental health diagnosis? If so, please give a description of your disorder.
Are you currently taking any long-acting injectable medication for schizophrenia, schizoaffective disorder, or bipolar disorder? If yes, please explain.
Income Sources
Employment Status
*
Employed full-time
Employed part-time
Unemployed
Student
Retired
Other
What type of housing are you looking for
*
short term housing
long term housing
temporary housing while waiting for section 8
Preferred Move-in Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the name of your physician and contact information
Emergency Contact Full Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Emergency Contact
*
Support Needs (select all that apply)
Mobility assistance
Mental health support
Substance use support
Declining memory issues
Medication reminder
Other
Please describe your support needs in more detail
Upload a picture of your Driver's License or State I.D.
*
Upload a File
Drag and drop files here
Choose a file
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Upload a picture of your Benefit Award Letter
Upload Benefit Award Letter
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Choose a file
Accepted formats: PDF or image, max 10MB.
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of
Signature (please sign below to confirm your consent)
*
Submit Application
Submit Application
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