New Horizon Living, LLC — Housing Pre-Screening Form

New Horizon Living, LLC — Housing Pre-Screening Form

Thank you for your interest in New Horizon Living. This pre-screening form helps us understand basic housing needs and determine appropriate next steps. Submission does not guarantee acceptance or placement, and room availability may change. Please do not submit Social Security numbers, medical records, diagnoses, medication lists, or other unnecessary sensitive information on this pre-screening form.
Person Completing the Form
Who are you completing this form for?

Other
Your full name

First NameLast Name
Your email
example@example.com
Your phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred contact method
Organization
Job title
Prospective Resident Information
Prospective Resident Full Name

First NameMiddle NameLast Name
Confirm Age 18 or Older
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current City
Current State
Preferred Contact Method
Housing Needs
Preferred move-in timeframe
Preferred room arrangement
Current housing situation
Brief description of housing need
Transportation to the residence available or planned?
Housing Payment / Funding
Expected housing-payment source

Other
Funding agency or program name
Monthly amount available for housing
Independent Shared-Living Fit
Can the prospective resident manage everyday personal needs independently?
Can the prospective resident manage medications independently or through an outside provider without New Horizon staff administering them?
Can the prospective resident follow household rules and shared-living expectations?
Can the prospective resident live respectfully with roommates?
Can the prospective resident manage appointments and transportation independently or with outside support?
Does the prospective resident require 24-hour supervision, skilled nursing, hands-on personal care, or medication administration from New Horizon Living?
If yes, display this message: New Horizon Living provides independent shared housing and does not provide medical, nursing, personal-care, medication-administration, or 24-hour supervision services. Applicants may continue if outside supports allow independent residency.
Would you like to request a reasonable accommodation during the housing process?
Referral / Support Information
Are you authorized to communicate with New Horizon Living, LLC about this housing inquiry?
Referral or support contact name

First NameMiddle NameLast Name
Agency or program name
Additional coordination notes
Required Acknowledgments
I understand that New Horizon Living provides independent shared housing and does not provide medical treatment, skilled nursing, hands-on personal care, medication administration, or 24-hour supervision.
I understand that submitting this pre-screening form does not guarantee acceptance, placement, or room availability.
I consent to New Horizon Living contacting me or the prospective resident about this housing inquiry.
Should be Empty:

New Horizon Living, LLC — Housing Pre-Screening Form

Person Completing the Form

Prospective Resident Information

Housing Needs

Housing Payment / Funding

Independent Shared-Living Fit

Referral / Support Information

Required Acknowledgments