• Free Housing + Support Review

    There are no wrong answers here — this helps us understand your situation so we can recommend the right starting point. A team member will always review this with you before anything is finalized.

  • Note: This form is step one  to determine housing fit — a second form, the formal application is seperate.

  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Who is completing this form?*
  • Who should be the primary contact for support-plan communication?
  • Format: (000) 000-0000.
  • Does this person live locally?
  • How often do they usually check in?
  • Are they able to help with errands, transportation, or meals?
  • Are they contributing financially?
  • Format: (000) 000-0000.

  • Housing Basics

  • Preferred room
  • Desired move date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Would you like us to check if you qualify for our Housing Subsidy Program?

  • Food + Groceries

  • Who currently purchases groceries?
  • Does the resident need help getting groceries into the home?
  • Would meal preparation help?

  • Transportation

  • Current transportation
  • Would help be useful with

  • Benefits + Resource Navigation

  • Which of these would be helpful to explore?
  • We'll help you explore, apply for, or connect to these — we can't guarantee approval or enrollment.

  • Functional / Scope Check

  • For each of the following, please indicate:
    Rows
  • Please check any that apply:
  • These go beyond what Bloom House Living provides directly — if any apply, that's completely okay, we'll talk through the right fit together.

  • Family Time + Burden

  • Approximately how much time does family/support spend each week coordinating needs?
  • What takes the most time?
  • How often does someone currently check on or assist the resident?*
  • Which statement best describes what you want Bloom to help with?*

  • Support Needs by Frequency

  • How urgent is the need for housing?*
  • Contact us anytime: 903-686-1804 • intake@jdehousingsolutions.com • jdehousingsolutions.com
  • Should be Empty: