ProjectFREE
Independent Living Tenant Application
Confidential intake for for adult applicants with diverse abilities
Date Received
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Month
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Day
Year
Date
Desired Move-In Date
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Application Reviewed By
Please complete all sections as thoroughly as possible. If an item does not apply, write N/A. Attach additional pages if more space is needed. This application may be completed by the applicant, family member, guardian, support coordinator, case manager, or another authorized representative.
1. Applicant Information
Applicant full legal name
Preferred name / nickname
Date of birth
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Month
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Day
Year
Date
Age:
Pronouns:
Current address
City / State / ZIP
Primary phone
Format: (000) 000-0000.
Secondary phone:
Format: (000) 000-0000.
Email
example@example.com
Primary language / communication method
Legal status
Independent adult
Guardian appointed
Power of attorney
Other
Application type
New applicant
Transfer applicant
Respite / trial stay
Reapplication
Current living situation
With family apartment
Independent
Group home
Supported living
Other
Tell us briefly why the applicant is interested in independent living with Project FREE:
Project FREE - Independent Living Tenant Application
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2. Guardian, Support Coordinator, and Key Professionals
Guardian / legal representative
Relationship to applicant
Phone:
Format: (000) 000-0000.
Email
example@example.com
Support coordinator / case manager
Agency
Phone:
Format: (000) 000-0000.
Email
example@example.com
Primary physician
Physician phone
Format: (000) 000-0000.
Dentist / specialist(s):
Behavior analyst / therapist / counselor
Other important providers
3. Emergency Contacts
List the people who should be contacted first in an emergency.
3. Emergency Contacts List the people who should be contacted first in an emergency.
Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
2
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Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
Emergency instructions, hospital preference, allergies, or critical medical alerts:
4. Immediate Family Information
Include parents, step-parents, siblings, spouse, adult children, or anyone the applicant considers immediate family.
Immediate family contacts
4. Immediate Family Information Include parents, step-parents, siblings, spouse, adult children, or anyone the applicant considers immediate family. Immediate family contacts
Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
2
3
4
Project FREE - Independent Living Tenant Application
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Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
2
5. Extended Family and Important Community Supports
Include grandparents, aunts, uncles, cousins, close family friends, pastors, neighbors, mentors, advocates, or others important to the applicant.
Extended family / community support contacts
Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
2
Project FREE - Independent Living Tenant Application
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Rows
Name
Relationship
Phone / Email
Address
Primary Contact
Visits / Involvement
1
2
Project FREE - Independent Living Tenant Application
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6. Health, Wellness, and Personal Care
Does the applicant currently take prescribed medication?
Yes
No
As needed only
Medication list, dosage, schedule, known side effects, and who assists with administration:
Medical / wellness areas that require support
Seizures
Diabetes
Mobility
Fall risk
Allergies
Mental health
Special diet
Other
Primary diagnosis / disability
Secondary diagnosis / needs
Insurance provider(s)
Pharmacy
Phone:
Format: (000) 000-0000.
Adaptive equipment used
Personal care supports needed
Describe bathing, toileting, dressing, grooming, hygiene, menstrual care, or other personal care needs:
7. Communication, Learning Style, and Daily Routine
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Best communication methods
How the applicant expresses choices / needs
Sensory preferences or triggers
Reading / writing / technology skills
Describe a typical weekday routine, including wake-up time, meals, work/day program, hobbies, and bedtime:
Favorite activities, interests, talents, calming strategies, motivators, and things that bring joy:
8. Safety, Behavior, and Supervision Needs
Level of supervision generally needed
Independent
Periodic check-ins
Daily prompting
Hands-on support
24-hour oversight
Safety concerns to be aware of
Elopement
Poor judgment
Medication safety
Cooking safety
Stranger awareness
Aggression
Self-injury
None known
Describe any behavioral supports, de-escalation strategies, trauma considerations, crisis history, or environmental risks staff should know:
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9. Independent Living Skills and Housing Readiness
Mark the box that best describes the applicant's current functioning. Use comments to explain supports, cues, or adaptations needed.
9. Independent Living Skills and Housing Readiness
Rows
Current ability / support needed
Comments / adaptive strategies
Goal priority
Meal prep / kitchen use
Medication self-management
Laundry
Cleaning / chores
Money management
Transportation
Community safety
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Rows
Current ability / support needed
Comments / adaptive strategies
Goal priority
Social skills with roommates
Social skills with roommates
Social skills with roommates
Social skills with roommates
Time management/scheduling
Self-advocacy
Social skills with roommates - Current ability / support needed
Independent
Prompting
Partial assist
Full assist
Social skills with roommates - Goal priority
High
Med
Low
Time management / scheduling - Current ability / support needed
Independent
Prompting
Partial assist
Full assist
Time management / scheduling - Goal priority
High
Med
Low
Self-advocacy - Current ability / support needed
Independent
Prompting
Partial assist
Full assist
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10. Housing History, Compatibility and Preferenes
Current residence and length of stay
Reason for seeking new housing
Past roomate experience
Have you ever been responsible for lease issues, property damage or have had past evictions?
Yes
No
If you answered yes, please explain in detail.
Pets/Service Animal
Check any that apply to you
Smoking
Vaping
Alchohol
Substance Abuse
If you selected any of the above, please explain further.
Describe what type of home environment is the best fit ( quiet, social, structured, flexible, co-ed preference, non-smoking, accessibility need, etc.)
What should staff and future housemates know to help the applicant be successful in shared housing?
11. Income, Benefits, Employment and Transportation
Income Source(s)
Monthy income amount
Representative payee (if none, write N/A)
Employment/ volunteer/ day program
Work schedule or program hours
Transportation used
Do you need transportation services
Yes
No
If yes, please specify your transportation needs, schedule, frequency/regularity (to and from work, doctors visits, extracurricular, etc.)
12. Goals for Independent Living
What are the applicant's top goals for moving into indepenent living in the next 6-12 months?
What skills does the applicant most want to build and what outcomes would make this placement a success?
13. Documents and Attachments Checklist
Please include copies if available in the file upload section below
Photo ID
Guardianship paperwork
Insurance Card
Medication list
Behavior plan
Support plan
Assessment/ ISP
Other records
Additional documents submitted or still pending
Please upload the above requested and any/all pertaining documents available
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14. Applicant Statement and Signatures
I certify that the information in this application is true and complete to the best of my knowledge. I understand that incomplete or inaccurate information may delay review. I authorize ProjectFREE to contact the people, agencies and professionals listed in this application for the purpose of evaluating housing fit and support needs, as permitted by law and any signed releases.
Applicant Signature
Date
Print name
Guardian/ Authorized Representative signature
Date
Guardian/ authorized representative print name below and include best phone number, email and relationship to applicant.
ProjectFREE intake staff signature
____________________________________________
Date
Internal note: Additional interviews, home visits, references or assessments may be requested as part of the admissions process.
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