Independent Living Intake

Independent Living Intake

Thank you for your interest in Gleaves Residential Solutions, LLC. We are committed to providing a safe, supportive, and stable living environment for individuals seeking a second chance and an opportunity to build a stronger future. Please complete the intake application below with accurate and truthful information. Your information will be reviewed to determine eligibility and placement availability.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Last Known Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Living Situation

Other
Please describe any support needs you have (mobility, daily living, medication, etc.)
Medical Conditions or Allergies
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
When are you looking to move?
How long do you plan to stay?
Reason for seeking a new place to stay?
Are you looking for a private or shared living arrangement?
Income Source
Are you able to afford program the monthly fee?
How did you hear about Gleaves Residential Solutions?
Why do you believe this housing opportunity is a good fit for you?
Is there anything else you would like us to know about your situation?
Applicant Certification & Consent : I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in denial of my application or termination of housing placement. I authorize Gleaves Residential Solutions, LLC to verify the information provided and to contact references, employers, or other appropriate sources as necessary to review my application and determine eligibility. By submitting this application, I acknowledge that I have read, understood, and agree to the above statement.
First and Last Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: