Application
  • Gender*
  • Race*

  • Date Of Birth*
     - -
  • Format: (000) 000-0000.
  • Are we permitted to contact you via text/voicemail on number provided?*
  • What is the client's desired move-in date?*
     - -
  • Current Living Situation*
  • Does the client prefer a private or shared room?*
  • Does the client have a history of mental health condition?*
  • Does the client have a disability?*
  • Do you take prescription medication? If Yes, are you medication compliant?*
  • Does the client require handicap living accessible living environment ?*
  • Is the client an ex-offender?*
  • Have you been convicted as a sex offender? (Answer does not disqualify you from our program/services)*
  • Are you currently on Probation or Parole? (Answer does not disqualify you from our program/services)*
  • Do you need help with recovering from substance abuse? (ex:opioid(s),alcohol.other drugs, etc) (Answer does not disqualify you from program/services)*
  • How does client intend to pay?*

  • How did you hear about us

  • Milestones Independent Living & Functionality Acknowledgment

    Our program is designed for individuals who are capable of living independently. We will assist clients with obtaining outside resources; however, you must be able to manage your own:
    • Personal hygiene and grooming
    • Meal preparation and eating
    • Medication (unless managed by an outside provider)
    • Mobility and transportation arrangements
    • Housekeeping and laundry
    • Daily living responsibilities
    If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver.

  • Should be Empty: