Intake Form
Fill out the form below to join the waitlist for independent living housing with Prosperity Pathways. Your information will remain completely confidential.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
0
01
011
0111
01111
Year
Marital Status
*
Single
Married
Divorced
Separated
Partnered
Current Living Situation
*
Homeless
Renting
With family or friends
Shelter
Transitional housing
Jail/ Prison release
Treatment Center
Other
Referral Agency / Source
Date of Housing Need
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you understand this home is for single occupancy only (one resident per bed/lease)?
*
Yes, I understand
No, I don't understand
Are you requesting housing for anyone other than yourself?
*
Yes
No
Source of Income
*
Employment
SSI/SSDI
Unemployment
Family help
Would you be able to provide proof of income?
*
Yes
No
Motherly Income amount
*
Are you able to Iive independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
Yes
No
Payment plan for rent
*
Weekly
Bi-Weekly
Monthly
Do you understand this is shared rooms only?
*
Yes
No, I prefer private room with higher monthly rate
I prefer to pay for private room
Yes
No
Would you need transportation assistance?
Yes
No
Do you have your own vehicle?
*
Yes
No
Do you have a valid identification card? (Drivers License,State ID,Passport etc;)
Yes
No
Do you understand that Prosperity Pathways ILF is a shared living program, and that by entering this housing environment you are agreeing to participate in a structured, supportive setting designed to help you build stability, independence, and healthy routines?
Yes, I understand
No, I don't understand
How do you prefer to be contacted?
*
via phone
via email
via text
Signature
*
Continue
Continue
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