Resident Waitlist Intake Form
Complete this form to join the Royal Haven Living Solutions (RHLS) waitlist and share your eligibility and housing needs.
Contact
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Text
Email
Housing
Current City
*
Preferred room type
*
Private room
Shared room
Either
Other
Can you afford a room starting at $750 for shared or $900–$1,000 for private?
*
Yes, shared room works
Yes, private room works
I need to discuss affordability
Income
Monthly income
*
Under $1,000
$1,000–$1,499
$1,500–$2,499
$2,500+
Income source
*
Employment
SSI/SSDI
VA Benefits
Retirement
Assistance
Other
Independence
Can you manage daily activities with or without outside assistance?
*
Yes
Yes with outside assistance
Prefer to discuss
Move-In
Move-in timeframe
*
Immediately
1–2 weeks
30 days
60+ days
Do you have a case manager?
*
Yes
No
Agency Name
Case Manager Name
Case Manager Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Referral source
Acknowledgment
Accessibility or reasonable accommodation needs
Agreement and Acknowledgment
Submit Application
Should be Empty: