Language
English (US)
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Intake Form
How many of the following daily living activities can you complete unassisted, please choose an answer from the dropdown menu for each question
Can you prepare & eat your own food?
*
Please Select
Yes
No
Need assistance
Are you able to respond to an emergency and get to a safe location in under 4 minutes?
*
Please Select
Yes
No
Need assistance
Can you get in and out of bed and move around freely on your own?
*
Please Select
Yes
No
Need assistance
Can you secure and manage your own healthcare?
*
Please Select
Yes
No
Need assistance
Can you maintain your own personal hygiene?
*
Please Select
Yes
No
Need assistance
Can you do your own laundry?
*
Please Select
Yes
No
Need assistance
Can you arrange for your own transportation?
*
Please Select
Yes
No
Need assistance
Can you do your own shopping?
*
Please Select
Yes
No
Need assistance
Can you manage your own finances?
*
Please Select
Yes
No
Need assistance
Can you use a telephone?
*
Please Select
Yes
No
Need assistance
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HOUSING INTAKE APPLICATION
It's important to note that our housing options are designed for shared living arrangements rather than individual occupancy. We appreciate your understanding and cooperation in this matter, when considering our housing program.
Are you currently considered homeless or transitioning out of homelessness?
Yes
No
Other
Today's Date
*
-
Month
-
Day
Year
Date
Who is this application for?
*
Please Select
Myself
Client (I am a case worker, referral agency, social worker, sponsor)
Applicant Full Name
*
First Name, Middle Initial, Last Name
Requested Move In Date
*
-
Month
-
Day
Year
Date
Rental request:
*
Shared room
Private Room
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
How did you hear about us?
*
Name of person/agency and phone number (if known)
Date of Birth
*
-
Month
-
Day
Year
DOB
Gender
*
Please Select
Male
Female
Other
Race
*
White/Caucasion
Black/African American
Asian
Other
If you selected female - Are you/client currently pregnant?
*
Please Select
Yes
No
Not sure
Have you/client lived in a shared/co-living environment before?
*
Please Select
Yes
No
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a residence or a business?
*
Please Select
Currently Homeless - No prior address
Business - Medical Facility
Residence - Group Home
Residence - Lived with Family
Residence - Lived alone
Residence - Lived with Roommates
If you/client are coming from another group home, please specify the name, how long you were living there and the reason for leaving.
*
Funding Source:
*
Please Select
SSI
SSDI
Govt/State organization
Non-Profit Organization
Self Pay
How are you/client payments paid?
Please provide the contact's name and number for the person/organization who will cover your costs?
*
Disbursement amount & date
SSI/SSDI - What is the amount & date that your payment is disbursed?
*
Disbursement amount & date
Self Pay - Are you/client currently employed?
*
Yes
No
Other
If you/client are currently employed - What is your/client monthly income?
*
Monthly Income
Employer Name & Number
*
Employer Information
Pay Cycle
*
Weekly
Bi-weekly
Other
Is this income amount consistent monthly or varies?
*
Monthly Income
A requirement of living at Boundless House LLC is to setup a Representative Payee or automatic direct deposit transfer to ensure on time payments and prevent delays in your living arrangements. Are you/client willing to setup this form of payment?
*
Yes
No
Do you have a probation officer or sponsor? If so, what is their name and phone/extention?
*
Do you have any food or drug allergies? If yes, please list below:
*
Are you currently attending Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings? If yes, please specify which one(s), date(s) and time(s):
*
Are you currently required to take prescribed medications?
*
Please Select
Yes
No
No, but currently seeking treatment
Are you willing to obtain & provide a brief summary of your diagnosis? (in case of medical emergency)
*
Reason you need placement? (Eviction, kicked out, moving, etc..)
*
Please provide an explanation IN DETAIL on why you were evicted, kicked out or needing to move
*
Are we able to contact your previous landlord/residence?
*
Please Select
Yes
No
Please provide the name and contact information of your previous landlord:
*
Do you smoke cigarettes, vape, cigars, or use marijuana?
*
Please Select
Yes
No
How long have you been in this situation?
*
Will there be anyone moving in with you? If so, please list name & age (Additional persons over 18 will need to complete a separate application, pets are not accepted)
*
Do you have a vehicle and require parking?
*
Do you have a vehicle and require parking?
Yes
No
Will need in the future
If we are unable to provide you with housing for any reason, we will be happy to assist with locating possible housing options at one of our partner homes. What other cities are you interested in relocating to? :
*
Is there any other important information that you feel we should be aware of (ex: will you require regular visits from family and/or care giver, medical staff, do you have any medical conditions, etc.)
*
Employer Information
Submit Application
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Thank you for your interest in Boundless House, due to your responses to our preliminary questionaire you do not meet the qualification criteria necessary to move forward in the housing application process at this time.
We understand this news may be disappointing, and we encourage you to explore other housing opportunities that may better suit your needs. Our homes are not currently equipped to provide personal daily need services and support to individuals. Should your circumstances change in the future, you are welcome to reapply. You can also reach out to
findhelp.org
to find other options in your area.
Thank you again for considering Boundless House. We wish you the best in your search for housing!
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