Apply Here (Approx. 10-15 mins) Name * First Name Last Name Date Of Birth * MM DD YYYY Email * Phone * (###) ### #### How did you hear about us? * Are you aware that this is shared living? * Yes No Gender * Male Female What services are you interested in? * Preferred Start Date * MM DD YYYY Current Living Situation * Current Address * How long are you planning to stay? * Do You currently have a case worker or a person assisting you with your affairs? * Yes No Funding Source * Self-Pay Social Security Insurance Government or State Organization Voucher Social Security Disability Insurance Non Profit Organization - Rent Assistance Are you currently employed * Yes No Where are you working? * What are working hours/ shift hours? * Would you consider a representative payee to ensure timely payments? If not, your rent will be due in advance to ensure good faith. * Yes No My payments are already taken care of by a third party. How much is your monthly income? * How often do you get paid? * Do you have any medical condition, if so please explain * Are you taking any medication? * Yes No Do you agree to taking a drug test before moving in and also participating in random drug tests. * Yes No Do you smoke, if so what do you smoke? * Are you currently in recovery for a particular addition? If so, please specify. * What is your primary mode of transportation? * Can you abide by the rules and regulations to ensure safety and harmony in the home. * Do you have any criminal charges or convictions? If so, please explain the nature of the charges and any associated outcomes. * Please provide us any additional information that you think would be helpful in helping us, help you! Thank you!
