APPLICATION

First name

Last name

Phone

What is your current living situation, and why are you seeking independent living at this time?

Are you able to manage your daily activities independently (bathing, dressing, meals, transportation)?

Do you currently receive SSI, SSDI, private pay income, or another form of assistance?

Do you have a case manager, social worker, or referring agency? If yes, please provide their contact information.

Are you currently taking any medications, and are you able to manage them on your own?

Do you have any medical, mental health, or behavioral conditions we should be aware of to support your housing placement?

Are you able to live cooperatively in a shared housing environment and follow house rules?

Do you have any legal restrictions, probation, or parole requirements that could affect your residency?

When are you hoping to move in, and do you have any special needs or accommodation requests?