Shared Housing Pre-Application
Elite Home Care & Housing is currently accepting applications for our all-inclusive, shared residences. Please fill out this form completely and someone will follow up with you as soon as possible!
Your Name
First Name
Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who are you applying for?
Myself
Family Member
A Client (I am a Case/Social Worker or Sponsor)
Client's Name
First Name
Last Name
Client's Email (if available)
example@example.com
Client's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to leave a message/text on the numbers provided?
Yes
No
Client Date of Birth
-
Month
-
Day
Year
Date
Client's Gender
Male
Female
What is the client's primary language?
Client's marital status
Single
Civil Union
Married
Divorced
Client's current living situation
Homeless shelter
Homeless (i.e. Street)
Hospital
Private Residence
Residential Care/Treatment
Prison/Jail
Single Room Occupancy
Reason for leaving:
Bedroom type the client is interested in?
Private Bedroom
Shared Bedroom
No Preference
Does the Client smoke?
Yes
No
Client's employment status
Employed full-time
Employed part-time
Unemployed - looking for work
Not in labor force
Which best describes the client's monthly income?
$699 or less
$700-$1000
$1001-$3000
$3001+
What is the client's funding source for this housing?
SSI
SSDI
Voucher
Private Pay
Retirement
Salary
Other
Who referred you to Elite Home Care & Housing?
Case Worker
Nursing Facility
Self
Google Search
Facebook
LinkedIn
Anticipated Move-In Date
-
Month
-
Day
Year
Date
How long does the client expect to be at Elite Home Care & Housing?
1 month
2-4 months
5-7 months
8 months +
at least 12 months
Submit
Should be Empty: