Tranquil Hearts Living LLC – Independent Living Pre-Screening Form

Tranquil Hearts Living LLC – Independent Living Pre-Screening Form

Complete this pre-screening to help Tranquil Hearts Living LLC assess whether independent shared housing may be a good fit (pre-screening only—no placement guarantee).
Applicant Information
Full Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address / Current Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best Way to Contact

Other
Referral Source
Preferred Contact Details
Current Housing Situation
Current living situation

Other
If your housing is unstable, how long have you been in this situation?
Desired move-in timeframe
Income & Benefits
Do you have steady income?
Income sources

Other
Estimated monthly income
Can you provide income verification before move-in?
Do you receive SNAP/EBT benefits?
Do you have a working phone?
Independent Living Readiness
Are you able to live independently without daily assistance?
Do you currently receive help with cleaning, cooking, hygiene, transportation, or other daily activities?
If yes, please explain what help you receive and how often.
Are you able to maintain your room and shared areas?
Are you comfortable sharing a home with others?
If you have difficulty sharing space, please explain.
Medications & Support
Do you take any prescribed medications?
Can you manage your medications independently?
Do you currently have a case manager or support worker?
Case manager or support worker name

First NameLast Name
Agency or organization
Case manager or support worker phone
Please enter a valid phone number.Format: (000) 000-0000.
Case manager or support worker email
example@example.com
Anything else about your mental health or support needs you want us to know
Disclaimer: Tranquil Hearts Living LLC does not administer, remind, monitor, or manage medications.
Housing Preferences & Accessibility
Preferred Room Type
Need Ground-Floor/Downstairs Room
Do You Have Mobility Limitations
Please Explain Mobility Limitations
Transportation Status
Need to Be Near a Public Bus Route
Background & Legal History
Note
Prior eviction
Felony conviction
Registered sex offender
Pending legal matters or court cases (please explain)
Lifestyle & House Expectations
Willing to follow house rules
Do you smoke or vape?
If yes, do you agree to smoke outdoors only?
Do you use alcohol?
Willing to comply with a drug-free housing policy
Do you have pets?
Cleanliness level
Understands and agrees to no unapproved guests, quiet hours, respect for others, cleanliness standards, and shared-living expectations
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Applicant
Additional Information
Why are you seeking housing at this time?
Anything else you'd like us to know to help determine fit
Applicant Acknowledgment
I certify that the information provided is true and complete to the best of my knowledge.
I understand that submitting this form does not guarantee acceptance, approval, or placement.
I understand that Tranquil Hearts Living provides independent housing only and does not provide meals, medical care, medication management, transportation, or personal care services.
I consent to be contacted regarding my pre-screening submission
Should be Empty:

Tranquil Hearts Living LLC – Independent Living Pre-Screening Form

Applicant Information

Current Housing Situation

Income & Benefits

Independent Living Readiness

Medications & Support

Housing Preferences & Accessibility

Background & Legal History

Lifestyle & House Expectations

Emergency Contact

Additional Information

Applicant Acknowledgment