• Program Application

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do we have permission to email, text or leave a message on the number provided?*
  • Do we have permission to email, text or leave a message on the number provided?*
  • Gender*
  • This form is being completed by*
  • This form is being completed by*

  • ***Are you interested in referring this client to Radiant Living4U's Emergency Rehousing Program? The Emergency Rehousing Program is available for agency-sponsored or approved third-party funded placements.**

  • Is this application for Emergency Rehousing through an agency or approved third-party funding source?*
  • Is this application for Emergency Rehousing through an agency or approved third-party funding source?


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    Funding source/program name: 
    Has funding already been approved?                        
    How long will the funding cover housing? 
    Requested placement date?      

  • Current Living Situation*
  • Referral Source (If Applicable)*
  • Desired Housing Location*
  • Preferred Move In Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently receiving mental health services or support that you plan to continue while participating in our program.*
  • Are you currently receiving mental health services or support that you plan to continue while participating in our program.*
  • Are you a veteran?*
  • Are you a veteran?*
  • Substance use history (if any)*
  • Are you willing and able to comply with living in a drug- and alcohol-free environment?*
  • Are you willing and able to comply with living in a drug- and alcohol-free environment?*
  • Are you a smoker?*
  • Are you a smoker?*
  • Are you currently on parole or probation*
  • Are you currently on parole or probation*
  • Any Pending charges?*
  • Any Pending charges?*
  • Are you currently required to register as a sex offender or subject to any residency restrictions?*
  • Are you currently required to register as a sex offender or subject to any residency restrictions?*
  • Do you have a source of income?**
  • Do you have a source of income?*

  • *Note: To be eligible for housing with Radiant Living4U, 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.**

  • How will Monthly Program fee be funded (check all that apply)*
  • Can you provide proof of income*
  • Can you provide proof of income*
  • Do you have a pet, service animal, or an emotional support animal (ESA)? (This does not automatically exclude you from the program. If yes, additional information may be requested during the screening process.)*

  • Note: Radiant Living4U 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.

  • Do you anticipate requesting, an assistance animal (including a service animal or emotional support animal) during your participation in the program?*
  • Do you anticipate requesting, an assistance animal (including a service animal or emotional support animal) during your participation in the program?*
  • Mobility Needs*
  • Do you understand that Radiant Living4U provides Shared Housing? (Shared housing means you will be living in a home with other Radiant Living4U program participants. Common areas such as the kitchen, living room, bathrooms, and laundry facilities are shared. **IF IN A SHARED SUITE YOU WILL HAVE A ROOMMATE.)*
  • Do you understand that Radiant Living4U provides Shared Housing? (Shared housing means you will be living in a home with other Radiant Living4U program participants. Common areas such as the kitchen, living room, bathrooms, and laundry facilities are shared. **IF IN A SHARED SUITE YOU WILL HAVE A ROOMMATE.)*
  • Preferred Room Type*
  • Radiant Livivng4U 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?*
  • Radiant Livivng4U 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 have or need a home health care provider or outside support service?*
  • Do you currently have or need a home health care provider or outside support service?*
  • I understand and agree that Radiant Living4U 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 and agree that Radiant Living4U 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 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.*
  • Are you (applicate) comfortable living in a shared household and participating in house chores?*
  • Are you (the applicant) comfortable living in a shared household and participating in house chores?*
  • Radiant Living4U enforces a strict zero-tolerance policy for drug and alcohol use. Are you (applicate) willing and ready to live in a 100% sober environment?*
  • Radiant Living4U enforces a strict zero-tolerance policy for drug and alcohol use. Are you (the applicant) willing and ready to live in a 100% sober environment?*
  • 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 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*
  • 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*
  • If immediate housing is not available through Radiant Living4U, do you give us permission to refer you to other similar housing programs or community resources that may be able to assist you?*
  • Should be Empty: