Luxe Haven Membership Assessment

  • Luxe Haven Membership Assessment

    Please ensure the application is completed in full. Incomplete submissions will not be considered for program membership.
  • Date*
     - -
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Gender*
  • Martial Status*
  • If you are in transition, please let us know which of the following best reflects your situation.*
  • Do you currently have a case manager, social worker, or program contact?*
  • Are you currently employed?*
  • Do you have a reliable source of income to cover the one time program fee, monthly room charges, and your personal expenses each month?*
  • Income Source*
  • Do you have a secondary source of income?*
  • Are you a veteran?*
  • How soon are you planning to move?*
  • Will you be the only person participating in the program or will there be someone else accompanying you?*
  • We offer co-ed (men & women), women-only, and men-only residences. Which setting are you most comfortable with?
  • Do you have or plan to bring any pet(s) with you?*
  • Do you require any daily assistance with personal care? (i.e. bathing, dressing, medication management, or mobility)*
  • If you are prescribed medications, do you take them independently? Please note: Luxe Haven is not a medical facility and cannot administer medication.*
  • Do you have any physical limitations or accessibility needs, or require medical supervision or specialized services to live safely day to day?*
  • Are you able to independently manage daily tasks like your meals, laundry, and cleaning of your living space without onsite staff support?*
  • This program is designed for independent adults only. It is not an assisted living, group home, or medical housing program. Do you acknowledge and understand this requirement?*
  • Are you comfortable living in a shared home community where common areas such as the kitchen, bathroom, living and laundry rooms, are used by other members in the residence?*
  • Are you comfortable sharing a semi-private bedroom with at least one other resident?*
  • Do you agree to follow all program rules, including quiet hours, visitor policies, and cleanliness standards?*
  • Have you ever been asked to leave a residence due to behavior, rule violations, or disturbances?*
  • To ensure we place you in the most suitable unit, are you able to safely and comfortably use stairs to reach bedrooms on the second floor?*
  • Have you ever been diagnosed with a mental health condition or received treatment for one?*
  • Have you had frequent 911 calls related to personal mental health crises? Please note, answering 'Yes' does not disqualify you.*
  • Have you ever been convicted of a violent crime or property damage? Please note, answering 'Yes' does not automatically disqualify you.*
  • Have you ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify you.*
  • Do you have any pending criminal or sexual convictions pending? Please note, answering 'Yes' does not automatically disqualify you.*
  • Are you currently on probation or parole?*
  • Our residences are alcohol and drug free (including marijuana). Are you able to comply with this requirement?*
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