25-8 Care Manor Waitlist Form
Please answer all required questions truthfully so we can get you placed when there's an opening.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Move In Timeline
How soon are you looking to move in?
*
ASAP
Within 30 days
30-60 days
Just exploring options
Income Information
What is your source of income?
*
Employment
SSI/SSDI
VA Benefits
Other
If other, please explain
Estimated monthly income (optional)
Under $800
$800-1200
$1200-$2000
$2000+
Referral Source
How did you hear about us?
*
Case Manager / Social Worker
Probation / Court
Social Media
Family or Friend
Other
Independent Living Eligibilty
Are you able to live independently without assistance?
*
Yes
No
Are you responsible for managing your own medications?
*
Yes
No
Does not apply
Background and Additional Info
Are you currently on probation or in a program?
*
Yes
No
Please share anything else you would like us to know (optional)
Agreement
By signing you agree with the statement "I understand this is an independent living home with no medical care, supervision, or personal assistance provided"
*
Join Waitlist
Join Waitlist
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