Application

Please complete the following application to help us assess your eligibility for our housing program. All information provided is confidential.

If you’d rather fill out a hard copy, you can download it in the box to the right.

Applicant Information Full Name: Date of Birth: Email Address: Phone Number:

Gender:
Male Female Prefer not to answer

Best way to contact you?
Phone Email Text

Bedroom Type

Shared environment with other independent individuals?
Yes No

Preferred room type:
Private Private Suite Semi-Private Semi-Private Suite

24/7 surveillance in shared space?
Yes No

Health / Medical History Please list any medical diagnosis you may have:

Independent Living Readiness

Can you perform your own ADLs (Ambulation, Bathing, Cooking, Dressing, Toileting)?
Yes No

Require assistance with any ADLs?
Yes No

Can you Climb Steps?
Yes No

Do you need Home Care Services?
Yes No

If yes, please select:
Bathing Dressing Ambulating Cooking Toileting

(Note: We do not provide medical care or ADL assistance.)

Daily Living & Compatibility

Okay with shared chores & quiet hours?
Yes No

How do you typically handle conflict with others?

Do you have any pets?
Yes No

If yes, how many?

Okay living with pets (if permitted)?
Yes No

Personal Background & Safety

Ever been evicted or asked to leave a program?
Yes No

If yes, explain:

Any criminal history we should know?
Yes No

Currently on probation or parole?
Yes No

Personal Goals & Lifestyle Main goals for living in this program: How long do you anticipate staying with us? When are you looking to move from your current environment?

Program Agreement & Policies

Able to adhere to all house rules?
Yes No

24/7 Surveillance Cameras in common areas: Is that ok with you?
Yes No

Agree to No-Tolerance Policy?
Yes No

Understand this is not an assisted living facility?
Yes No

Authorization & Signature

I certify that all information provided is accurate. I understand submission does not guarantee placement.

Applicant Signature: Date:

Application

Downloadable Form