Community Support & Housing Application
Please complete the application with your applicant information, emergency contact, referral source, housing request, functional and mobility details, income and finances, medical and support needs, background, and acknowledgement. All fields are optional unless indicated otherwise.
Applicant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security # (last 4 digits)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Address / Location
*
Emergency Contact
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Source
Referral Source
*
Self
Hospital / Rehab
Case Manager / Social Worker
Shelter / Outreach Program
Veteran Program
Other
Referral Source - Other
Referral Organization Name
Referral Contact Person
Referral Phone / Email
Housing Request
Preferred Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Length of Stay Requested
*
Month-to-Month
3 Months
6 Months
Other
Length of Stay - Other
Room Type
*
Private Room
Shared Room
Functional and Mobility Details
Can you live independently (bathe, dress, feed yourself)?
*
Yes
No
Do you require mobility assistance?
No
Walker
Wheelchair
Other
Mobility Assistance - Other
Income and Finances
Primary Source of Income
*
Employment
SSI / SSDI
Veteran Benefits
Retirement
Other
Primary Source of Income - Other
Monthly Income Amount
*
Do you have funds available for move-in?
*
Yes
No
Medical and Support Needs
Do you have any diagnosed medical conditions?
*
Yes
No
If yes, list diagnosed medical conditions
Do you take prescribed medications?
*
Yes
No
Are you currently under care of a provider?
*
Yes
No
Do you require home health services?
*
Yes
No
Background and Acknowledgement
Have you been evicted in the past 5 years?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
Have you ever been convicted of a violent or sexual offense?
*
Yes
No
Are you willing to follow house rules?
*
Yes
No
Applicant Signature
*
Date (Acknowledgement)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: