• Program Application

  • Today's date*
     - -
  • Date of Birth*
     - -
  • Do we have permission to email, text or leave a message on the number provided?*
  • Gender*
  • This form is being completed by*
  • Are you interested in referring this client to Sable Haven’s Emergency Rehousing Program? The Emergency Rehousing Program is available for agency-sponsored or approved third-party funded placements.*
  • What best describes your current living situation?*
  • Referral Source (If Applicable)*
  • Preferred Move In Date*
     - -
  • Desired Housing Location*
  • Are you currently receiving mental health services or support that you plan to continue while participating in our program?*
  • Do you have a history of substance use that you would like us to be aware of?*
  • I understand that Sable Haven is a drug and alcohol free program, and I agree to comply with this requirement throughout my participation in the program.*
  • Do you anticipate bringing an animal with you if accepted into the program?*
  • If yes, please indicate:

  • Note: Sable Haven complies with all applicable federal, state, and local fair housing laws regarding service animals and emotional support animals. Additional documentation may be requested for emotional support animals when permitted by law.

  • Are you currently on parole, probation, or subject to any legal supervision or housing restrictions?*
  • Are you currently required to register as a sex offender or subject to any residency restrictions?*
  • Do you currently receive a verifiable source of income that can support the monthly program fee?*

  • *Note: To be eligible for housing with Sable Haven Independent Living, all applicants must have a verifiable source of income. This may include employment, SSI, SSDI, VA benefits, retirement income, agency or program sponsorship, or another documented source of income. Income verification is required before admission.*

  • Income Source*
  • Are you able to provide proof of verifiable income (such as recent pay stubs, SSI/SSDI award letter, VA benefits, pension, or other income documentation)?*
  • Preferred Room Type*
  • Sable Haven is an independent living program and does not provide assistance with activities of daily living (ADLs). Can you independently perform your activities of daily living (ADLs), including bathing, dressing, toileting, transferring, eating, and personal hygiene?*
  • Do you currently receive assistance from a home health agency, personal care attendant, or other supportive service provider?*
  • I understand and agree that Sable Haven Independent Living is a housing program and does not provide medical care, personal care, supervision, or assistance with activities of daily living. I am responsible for managing my own personal care, medical needs, medications, transportation, and daily living tasks.*
  • I understand that, if accepted into the program, I am expected to follow all house rules, program guidelines, and participate in any required meetings, case management services, or program-related check-ins.*
  • I acknowledge that failure to comply with house rules or program expectations may result in disciplinary action, including the issuance of a strike or dismissal from the program.*
  • I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that submitting this application does not guarantee acceptance or placement in the program. All applications are subject to review, eligibility verification, and program availability.*
  • Should be Empty: