Form

Next Phase Living Intake Form

Please complete this form to be considered for housing with Next Phase Living. This is a structured shared living environment. Only qualified applicants will be contacted.
Basic Information
*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current City & State
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Emergency contact name and number

Income & Ability to Pay

Please answer honestly. This information helps determine eligibility.
What is your total monthly income? (Enter exact amount)*
What type of income do you currently receive?*
If you selected other, please briefly explain your income source.
Are you able to consistently pay your monthly program fee?*
How long have you been receiving this income?*
Are you able to provide proof of income?*

YesNo
Are you able to consistently meet the monthly program fee of $700-$900?*

YesNo

Background & Final Questions

Please answer honestly. This information helps determine placement eligibility.
Next Phase Living is a structured independent living program with rules and expectations. Are you willing to follow all program guidelines?*

YesNo
Do you currently have any substance use concerns that may affect your ability to follow program rules?*

YesNo
Are you currently under case management or enrolled in a housing program?*
If yes: Please briefly explain.
Why are you seeking housing at this time? (Please be specific)*
Is there anything else you would like us to know about your situation? ( optional)
Please review your responses before submitting.
I understand that Next Phase Living is a structured independent living program, and submission of this form does not guarantee placement. I agree to follow all program rules and expectations if accepted.*

Yes, I understand and agree
Should be Empty:

Next Phase Living Intake Form