LifeSavers Pathways to Independence (Application)

1. Full Name *

2. Date of Birth

3. Current Address

4. Phone

5. E-mail *

6. Where were you referred from? (Agency, case manager, family member, self, etc.) *

7. Emergency Contact / Next of Kin

8. Emergency Contact / Next of Kin

9. Income

10. Additional Income

11. Do you have a steady source of income?

Answer

Yes

Answer

No

Answer

12. What is your main source of income?

Answer

SSI

Answer

SSDI

Answer

Employment

Answer

VA Benefits

Answer

Other:_______

Answer

13. What is your estimated monthly income? (We may aske for confirmation - proof can be shown in person or sent electronically.)

14. Do you receive Food Stamps / EBT (SNAP benefits)?

Answer

Yes

Answer

No

Answer

15. Do you have a working phone we can use to contact you?

Answer

Yes

Answer

No

Answer

16. Are you able to live independently without daily assistance?

Answer

Yes

Answer

No

Answer

17. Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?

If yes please explain:_______________________________________________________________

Answer

Yes

Answer

No

Answer

18. Are you currently taking any prescribed medications?

If yes, Please explain____________________________________________________________

Answer

Yes

Answer

No

Answer

19. Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?

If yes, Please explain____________________________________________________________

Answer

Yes

Answer

No

Answer

20. What type of room are you looking for?

Answer

Shared Room

Answer

Private Room

Answer

Private Room with Bathroom

Answer

No Preference

Answer

21. When do you need housing? (Move-in date):

22. Do you have any physical disabilities or mobility concerns?

If yes, Please explain____________________________________________________________

Answer

Yes

Answer

No

Answer

23. Have you ever been evicted from a previous residence?

If yes, Please explain____________________________________________________________

Answer

Yes

Answer

No

Answer

24. Have you ever been convicted of a felony?

Answer

Yes

Answer

No

Answer

25. Are you a registered sex offender?

Answer

Yes

Answer

No

Answer

26. Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?

Answer

Yes

Answer

No

Answer

27. Do you smoke?

Answer

Yes

Answer

No

Answer

28. Do you have any pets?

Answer

Yes

Answer

No

Answer

29. Why are you seeking housing at this time

30. Is there anything else you'd like us to know?

31. Document upload

Choose a file or drag it here

I agree to the terms and conditions

32. Signature

Clear

33. Date