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Application

What's is your name?

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Gender?

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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

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?

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Are you taking any prescribed medication?

A

No

B

Yes, (list medications)

Do you manage your medications independently?

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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?

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Anxiety or panic attacks?

A

Yes

B

No

Suicidal thoughts?

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Suicidal thoughts?

A

yes

B

No

Psychiatric hospitalization?

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Psychiatric hospitalization?

A

Yes

B

No

If yes, explain

Do you have a case manager, therapist, or support worker?

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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 ?

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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?

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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?

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Have you ever been evicted from housing?

A

No

B

Yes , why

Can you pay rent consistrntly?

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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