LEGACY HAVEN PRIME Waitlist & Pre-screening

LEGACY HAVEN PRIME

WAITLIST & PRE-SCREEN
Name

First NameLast Name
Date of birth:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method:

PhoneTextEmail
Are you seeking housing for yourself or someone else?

MyselfSomeone else
What type of room are you seeking?

Shared roomPrivate roomEither is a fine
Do you have income or funding that can support the program fees?

YesNoWorking with a Caseworker
  If funded by a Caseworker provide contact info:
First Name   Last Name
Agency
Area Code   Phone Number
Email
What is your income or funding source? (Check all that apply)

SSISSDIEmploymentVA BenefitsCaseworker ProgramOther
Monthly income amount:
Are you able to provide proof of income or benefits?

YesNo
When are you looking to move in?

ASAP1-2 weeks30 daysGathering Information
What is your Veteran Status?
Do you understand that this is structured, quiet shared housing for adults? (Not a rehab or medical facility)

YesNo
Have you lived in shared or structured housing before?

YesNo
Additional Notes (optional):
Do you have any concerns about shared housing?
By submitting, I understand this places me on the Legacy Haven Prime waitlist and does not guarantee placement.

I understand.
Signature (E-Signature is OK)

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