Grace Point Independent Living - Intake Form
Share your details, room preference, eligibility, and emergency contact to apply.
About You
Full Name
*
First Name
Last Name
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Where do you live now?
*
Please Select
Hospital or rehab facility
Staying with family or friends
Shelter or temporary housing
My own home or apartment
Other
Room You Want
Room Selection
*
prev
next
( X )
Shared room (two residents)
$850 per month
$850.00
$
850.00
Private room, no bathroom
$900 per month
$900.00
$
900.00
Private room with bathroom
$950 per month
$950.00
$
950.00
Earliest Move-In Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eligibility
Which of these describe you?
*
Age 45 or older
Veteran
Adult with a disability who can care for myself
How do you pay for housing?
*
SSDI
SSI
Steady income from work, a pension, or other sources
Please acknowledge: I can manage my own medications, feed myself, bathe myself, and use the restroom without help. I understand Grace Point has no on-site nurses.
*
I acknowledge
Please acknowledge: I agree to the house standards: no smoking, no drinking, and no non-prescription drug use.
*
I agree
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to You
Please Select
Spouse or Partner
Parent or Guardian
Adult Child
Sibling
Other Relative
Friend
Other
A Few More Things
Who is filling out this form?
*
Please Select
I am applying for myself
A family member or friend
A social worker or case manager
A discharge nurse
Helper’s name (if someone else is assisting)
Helper’s organization (if applicable)
Anything else you want us to know
Please do not enter sensitive identity details, financial information, or medical records here.
Submit
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