Application form

Full name *

Date Of Birth *

Emergency contact name *

Phone number

What is your current housing situation?

How soon do you need housing?

Are you looking for temporary or long-term housing?

Temporary

Long-term

What type of room are you interested in?

Private

Shared

Are you comfortable sharing a bathroom, kitchen, and common areas?

Yes

No

Do you have reliable transportation?

Yes

NO

Do you currently receive regular monthly income?

Yes

No

What is your source of income?

Employment

Social Security retirement

SSI

SSDI

Veterans benefits

Other income

What is your total monthly income? *

How often do you receive your income?

Weekly

Biweekly

Twice monthly

What date do you typically receive payment?

Will you be paying your housing fees yourself?

Yes

No

organization, family member, or other third party assist with payment

When would you be ready to make your first housing payment?

Can you independently manage your daily routine, or with support you arrange yourself?

Yes

NO

Can you manage your own meals and personal hygiene, or arrange any needed assistance independently?

Yes

No

Can you independently manage your medications, if applicable, or arrange outside support?

Yes

No

Do you currently receive outside services that you would like to continue while living in the home?

Yes

No

Do you understand that this housing program does not provide medical or personal care services?

Yes

No

Are you willing to respect quiet hours and other residents' privacy?

Yes

No

Are you willing to clean up after yourself and maintain shared spaces?

Yes

NO

Are you willing to follow the property's smoking, alcohol, and substance-use policies?

Yes

No

Do you smoke or vape?

Yes

No

Are there any current legal restrictions or court orders that would affect where you can live or your ability to comply with the housing agreement?

Yes

No