Mae's Independent Living Intake Form
Fill out the form below to join our wait list for independent living housing with Mae's Village. Your information will remain confidential.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Nonbinary
N/A
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Prefer not to say
Current Living Situation
*
Living alone
With family
With roommates
Group home
Couch surfing
Shelter
Transitional housing
Jail / prison
Treatment center
Other
Current Address (if applicable)
Referral Agency/Source
Date Housing is Needed
*
Source of Income
SSI/SSDI
Employment
Retirement
Unemployment
Wages
Food stamps
Military VA benefits
Family support
Would you be able to provide proof of income?
*
Monthly Income ($)
*
Payment plan for the program fee
*
Weekly
Biweekly
Monthly
What level of support do you require for daily living?
*
No support needed
Occasional support
Regular support
24/7 support
Are you requesting housing for anyone other than yourself?
*
Yes
No
Do you need transportation assistance?
*
Yes
No
Do you own a vehicle?
*
Yes
No
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you understand that Mae's Village is an independent shared living housing program and that by entering this housing program environment, you are agreeing to participate in a structured supportive setting that is designed to help you maintain your independence, achieve your goals, and thrive.
*
Yes. I understand.
No. I don't understand.
How do you prefer to be contacted?
*
via text
via phone
Signature
*
First Name
Last Name
Submit Application
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