Prospective Resident Waitlist Intake Form
Complete this form to join the Royal Haven Living Solutions (RHLS) waitlist and share your eligibility and housing needs.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
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
Current Situation
Current City
*
Current Housing Status
*
Renting
Homeless
Shelter
Staying with Family/Friends
Transitional Housing
Other
Desired Move-In Timeframe
*
ASAP
Within 30 Days
Within 60 Days
3+ Months
Case Management
Are you currently working with 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
Program Eligibility
Are you able to live independently without daily medical or personal care assistance?
*
Yes
No
Source of Income
*
Employment
SSI
SSDI
VA Benefits
None
Other
Referral Information
How did you hear about Royal Haven Living Solutions?
Additional Information
Please share any additional information about your housing needs.
Agreement and Acknowledgment
Submit Application
Should be Empty: