Self Pay Application Form

Self Pay Application Form

Apply for transitional and independent living housing and indicate self-pay status. Complete the required contact details and provide the requested background, income, support, and consent information.
Applicant Personal Information
Applicant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Preferred Name
Any Other Basic Identifying Details
Contact Details
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Demographic Information
Ethnicity
Race

Other
Preferred Language
Program Eligibility and Background
Are you a veteran?
Are you currently involved with the justice system or re-entering the community after incarceration?
Current living situation
Please share any brief details about your background or current situation
Income and Self-Pay Ability
Current income source(s)

Other
Current monthly income amount
Can you self-pay for services?
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Relationship to Applicant
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Support Needs
Please describe any support needs or accommodations you would like us to know about
Which support areas apply to you?

Other
Consent and Agreements
I agree to the following
Applicant signature
Should be Empty:

Self Pay Application Form

Applicant Personal Information

Contact Details

Demographic Information

Program Eligibility and Background

Income and Self-Pay Ability

Emergency Contact

Support Needs

Consent and Agreements