Page 1 of 1
Application
What's is your name?
*
Gender?
*
Gender?
A
Male
B
Female
Date of Birth
*
What's your phone number
*
What's your email?
*
What is your monthly income?
*
Provide Proof of Income
Click to choose a file or drag here
Size limit: 10 MB
Click to choose a file or drag here
Size limit: 10 MB
Are you interested in a share or private room
*
How soon are you looking into moving
*
We provide housing for independent individuals. Are you independent?
*
We provide housing for independent individuals. Are you independent?*
A
yes
B
no
Have you ever been diagnosed with any mental health conditions?
*
Have you ever been diagnosed with any mental health conditions?
A
No
B
Yes,(therapy, medication, both)
Are you currently receiving treatment?
*
Are you currently receiving treatment?
No
Yes, list treatment.
Are you taking any prescribed medication?
*
Are you taking any prescribed medication?
A
No
B
Yes, (list medications)
Do you manage your medications independently?
*
Do you manage your medications independently?
Yes
No
Need assistance
In the past 2 months, have you experienced Severe depression:
Untitled multiple choice field
A
Yes
*
B
No
Anxiety or panic attacks?
*
Anxiety or panic attacks?
A
Yes
B
No
Suicidal thoughts?
*
Suicidal thoughts?
A
yes
B
No
Psychiatric hospitalization?
*
Psychiatric hospitalization?
A
Yes
B
No
If yes, explain
Do you have a case manager, therapist, or support worker?
*
Do you have a case manager, therapist, or support worker?
A
No
if yes, explain
*
Do you have any medical conditions we should be aware of ?
*
Do you have any medical conditions we should be aware of ?
A
No
B
If yes, explain
Do you require assistance with any of the following:
*
Do you require assistance with any of the following:
Bathing
Dressing
Cooking
Mobility
Medication reminders
None
Do you use any of the following
*
Do you use any of the following
Wheelchair
Walker
Cane
None
Any Allergies (food/medication/environmental)?
*
Any Allergies (food/medication/environmental)?
No
YES
If, yes explain
Have you ever been convicted of a violent offense?
*
History of aggressive behavior?
*
History of aggressive behavior?
A
No
B
Yes, explain
Any history of:
*
Any history of:
A
substance abuse
B
Alcohol dependency
C
Drug use
D
No history
if yes, are you currently in recovery?
Are you able to live peacefully with others in a shared environment?
*
Are you able to live peacefully with others in a shared environment?
A
Yes
B
No
Have you ever been evicted from housing?
*
Have you ever been evicted from housing?
A
No
B
Yes , why
Can you pay rent consistrntly?
*
Can you pay rent consistrntly?
A
Yes
B
No
" I understand that this a shared living environment and I agree to follow all house rules, maintain respectful behavior and provide truthful information."
*
Signature
Submit