• Participant Enrollment Application

  • Participant Information

  • Date of Birth: *
     - -
  • Format: (000) 000-0000.

  • SMS Opt-In:

    By submitting this application you agree to receive SMS text messages from Tailored Community Purposes LLC and agree to all its SMS and text messaging policies and terms.  Messaging and data rates my apply.  Click here to view details.  Reply STOP to unsubscribe. Reply HELP for assistance.

  • Gender:*
  • Are you a Veteran?*

  • Emergency Contact Information

  • Format: (000) 000-0000.

  • Referral Source

  • Referral Source Options:*
  • Format: (000) 000-0000.

  • Current Living Situation

  • Where do you live now? List all that apply:*

  • Mental Health & Diagnosis

  • Are you currently prescribed any medications?*
  • Do you have trouble obtaining medications due to cost, transportation, insurance, or other barriers?*
  • Are you able to manage your own medication?*
  • Do you require reminders for medications or appointments?*
  • Do you have any mental health diagnoses you would like us to be aware of?*
  • Do you currently receive case management, peer support, or other community-based services?*

  • Substance Use History

  • Substance abuse and/or excessive use history:*
  • If yes, do you attend any support meetings?*
  • Do you smoke or vape?*
  • Do you consume alcohol?*

  • Background & Legal History

  • Have you ever been evicted?*
  • Have you ever been convicted of a felony?*
  • Have you ever been convicted of a violent crime?*
  • Are you currently registered as a sex offender?*
  • Do you have any pending legal matters, probation requirements, or court cases?*
  • Are you currently on parole or probation?*
  • Format: (000) 000-0000.

  • Income Information

  • Do you have a steady source of income?*
  • Are you currently employed?*
  • What is your primary source of income? List all that apply.*
  • Format: (000) 000-0000.
  • Do you receive SNAP/EBT benefits?*
  • Do you have a working phone that we can reliably contact you on?*
  • Are you able to pay the Community Fee prior to move-in?*
  • Do you understand that the Community Fee must be paid before move-in?*

  • Housing Preferences or Needs

  • Housing Need:*
  • Requested Move In Date:*
     / /
  • Preferred Room Type:*
  • Do you have any disabilities or mobility limitations?*
  • Do you require special needs for accommodations?*
  • Do you require a ground-floor room?*
  • Do you have reliable transportation?*
  • If not, do you need housing near public transportation?*

  • Lifestyle & House Expectations

  • Are you willing to comply with all house rules, including cleanliness standards, guest policies, quiet hours, and respect for other residents?*
  • Do you currently use illegal drugs?*
  • Do you have any difficulty sharing living space with others?*
  • Have you lived in an independent shared living facility before?*
  • Have you ever been asked to leave any type of housing program, shelter, or shared living environment?*

  • Independent Living & Functionality Acknowledgment

  • Our program is designed for individuals who are high-functioning and capable of living independently. This program is not a personal care home, nursing home, or assisted living facility. We do not provide any short or long term medical care, personal assistance, consistant meals or supervision.

  • You must be able to manage your own Activities of Daily Living (ADL's) which are the basic, routine self-care task required to function and live independently.

     

    • Personal hygiene and grooming
    • Meal preparation and eating
    • Medication (unless managed by an outside provider)
    • Mobility and transportation arrangements
    • Housekeeping and laundry
    • Daily living responsibilities 

  • If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

  • Are you able to live independently and manage your Activities of Daily Living (ADLs) without assistance?*
  • Do you currently have or need a home health care provider or outside support service?*

  • Program Agreement Preview

  • I understand and agree that this program provides housing only.  I will be responsible for my personal care, medical needs, consistant meals, and daily living tasks.  I will not hold the Tailored Community Purposes LLC or the program responsible for services outside the scope of independent housing.

     

    I understand that if accepted, I must follow all the program and house rules, stipulations, expectations, and participate in case management or program-related check-ins. I acknowledge that violating any of the rules, policies and/or terms may result in a strike, termination and dismissal from the program.

  • Applicant Declaration

  • I certify that the above information is true to the best of my knowledge.  I understand that completing this form does not guarantee placement, and my application will be reviewed by staff.  I understand that providing false or misleading information may affect my eligibility for housing placement.

  • HIPPA:

    To review or HIPPA and Background Check policies, terms and conditions go to: https://app.jotform.com/261662349237159/page/186 

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