Twelve28 Care Solutions — Quick Housing Interest Form

1
Program-Fit Screening. Twelve28 Care Solutions provides independent shared housing with practical, non-clinical support. We do not provide skilled nursing, medication administration, hands-on personal care, detoxification, clinical treatment, crisis stabilization, or 24-hour supervision. Please answer honestly so the team can determine whether Twelve28 may be an appropriate level of housing and support.
2
Full Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Preferred Contact Method* This field is required.
Phone
Text
Email
6
Who is this application for?* This field is required.
Myself
Someone I am helping
7
Target Move-In Date* This field is required.
Date
Month
Day
Year
8
Current Housing Situation / Reason for Seeking Housing* This field is required.
9
Do you have verifiable income?* This field is required.
Yes
No
Unsure
10
Income Source* This field is required.
Employment
SSI/SSDI
VA Benefits
Family Support
Agency/Case Management Funding
Other
Other
11
Approximate Monthly Income* This field is required.
12
If approved, are you prepared to pay the required enrollment fee?* This field is required.
Yes
No
Unsure
13
Can you independently manage your personal care and routine daily activities without hands-on assistance from Twelve28 staff?* This field is required.
Yes
No
Unsure
14
Can you independently manage and take your own medications without Twelve28 staff administering or managing them?* This field is required.
Yes
No
Unsure
15
Do you currently require 24-hour supervision, hands-on personal care, skilled nursing, assisted-living services, or another level of care beyond independent housing?* This field is required.
No
Yes
Unsure
16
Are you currently seeking or requiring detoxification, inpatient treatment, crisis stabilization, or another clinical treatment setting?* This field is required.
No
Yes
Unsure
17
Is there a current, unmanaged safety concern that could make living safely in a shared home difficult for you or other residents?* This field is required.
No
Yes
Unsure
18
If yes or unsure, please briefly explain.
19
Are you willing and able to live respectfully in a shared-home environment and follow Twelve28's expectations regarding cleanliness, visitors, quiet hours, safety, and community living?* This field is required.
Yes
No
I have questions
20
Referral Source* This field is required.
Self
Family/Friend
Agency/Case Manager
Other
21
Agency/Organization
22
Case Manager/Referral Contact
23
I understand that this is an initial housing interest and program-fit screening only. Submission does not guarantee acceptance, placement, or room availability. Twelve28 Care Solutions will review my information and contact me regarding next steps if the program may be an appropriate fit.
24
Acknowledgment* This field is required.
25
Applicant Name* This field is required.
First Name
Last Name
26
Date* This field is required.
Date
Month
Day
Year
27
Campaign Source
Should be Empty: