Haven Cove Manor Independent Living Housing Referral & Pre-Screening Questionnaire

Haven Cove Manor Independent Living Housing Referral & Pre-Screening Questionnaire

Thank you for your interest in Haven Cove Manor Independent Living. This brief questionnaire helps us determine whether our structured independent living program may be an appropriate fit for the applicant. If the applicant appears to meet our preliminary eligibility requirements, we will contact you regarding the next steps in our review process. Completing this questionnaire does not guarantee acceptance into the program. Haven Cove Manor is a non-medical, structured shared housing program for adults who are able to live independently and manage their own daily activities.
Who is completing this Housing Referral & Pre-Screening Questionnaire?

Other
Referral Contact Information

Please provide your contact information below. If you are completing this questionnaire on behalf of the applicant, we may contact you regarding the referral.
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Organization / Agency (if applicable)
Job Title (if applicable)
Organization Phone (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Organization Email (if applicable)
example@example.com
When is housing needed?
Applicant Information
Name

First NameLast Name
Applicants Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Gender

Other
Current Housing Situation

Other
Current City
Current County
Current State
Preliminary Eligibility

Please answer Yes or No.
The applicant is able to bathe, dress, use the bathroom, and move about independently without hands-on assistance.
2. The applicant independently manages, stores, and takes their own medications without assistance or reminders.
The applicant understands that Haven Cove Manor does not provide: Nursing care, Medication management, Personal care, Transportation and behavioral health treatment. They are responsible for managing their own daily activities.
The applicant has a reliable monthly source of income sufficient to meet the program's housing fees.
What is the applicant's primary source of income?

Other
The applicant is willing to live respectfully in shared housing and follow Haven Cove Manor's House Rules, including visitor policies, quiet hours, cleanliness expectations, and community living standards.
Haven Cove Manor maintains a drug- and alcohol-free living environment. Is the applicant willing to comply with this policy?
Is the applicant currently connected with a Case Manager, Social Worker, VA Representative, Care Manager, or other support professional?

Other
Agency
Contact Person
Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Housing Needs
Briefly describe why the applicant is seeking housing.
How did you hear about Haven Cove Manor?

Other
Acknowledgment
Please review your responses for accuracy before submitting. By submitting this questionnaire, you acknowledge that the information provided is true and complete to the best of your knowledge. Completing this questionnaire does not guarantee acceptance into Haven Cove Manor Independent Living. If the applicant appears to meet our preliminary eligibility requirements, we may contact you regarding the next steps in our review process.☐ I understand and agree.
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Haven Cove Manor Independent Living Housing Referral & Pre-Screening Questionnaire

Referral Contact Information

Applicant Information

Preliminary Eligibility

Housing Needs