Independent Living Application
Complete this form to help us understand your housing needs and goals.
Section 1: Basic Information
Full Legal Name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Email Address
*
Current City & State
*
Best Way to Contact You
*
Phone Call
Text Message
Email
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Section 2: Current Situation
Current living situation
*
Staying with family/friends
Shelter
Hotel/Motel
Apartment/Home
Homeless
Other
Is your current living environment safe?
*
Yes
No
Unsure
Do you feel your current living situation is safe?
*
Yes
Somewhat
No
If “Somewhat” or “No,” please share anything you feel comfortable sharing:
Job/Employer
Hours per week
Are you currently employed?
*
Full-Time
Part-Time
Self-Employed
Unemployed
Student
Other
Source(s) of monthly income
*
Employment
Government Assistance
Child Support
Disability
Family/Friends
No Current Income
Other
Do you have reliable transportation?
*
Yes
No
Sometimes
Section 3: Program Fit
Have you lived in a structured home before?
*
Yes
No
Why are you seeking independent living support at this time?
*
Areas you want support
Budgeting & financial literacy
Emotional regulation
Social skills & community
Time management
Cooking / cleaning skills
Education & certifications
Goal Setting
Healthy routines & outlets
Linkage to mental health services
Are you willing to participate in a structured and respectful shared living environment?
*
Yes
No
Do you have any current mental-health diagnoses?
*
Yes
No
If yes, please list any current diagnoses:
Are you open to following house expectations and community guidelines?
*
Yes
No
Have you previously lived in shared housing or a group living environment?
*
Yes
No
Section 4: Support Needs
Are you currently receiving counseling, mentoring, or case management services?
*
Yes
No
Do you have any medical, mental health, or support needs you would like us to be aware of?
Is there anything that could impact your ability to safely live in a shared environment?
Section 5: Timeline & Availability
When are you hoping to move into Independent housing?
*
Immediately
Within 30 Days
Within 60 Days
Flexible/Waitlist
How long are you inquiring about stay?
*
1-3months
3-6months
6-12months
How did you hear about House of Becoming?
*
Church
Social Media
Friend/Family
Referral Agency
Community Event
Website
Other
If referred by an organization or caseworker, please provide their name and contact information.
Section 6: Agreement
I understand that submitting this application does not guarantee placement in the House of Becoming Independent Living Program. I certify that the information provided is accurate to the best of my knowledge.
*
I agree
Date
Signature
Submit Application
Submit Application
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