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Independent Living Community Homes

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Independent Living Intake Form

Please complete the form below to apply for our Independent Living program.

Contact Information

Name
Email

Household Information

Tell us about other people living with you.
Please list their full name, age, and relationship to you (Example: 1. Jane Doe -42 -Spouse 2. John Doe Jr.- 18 -Son)

Demographic Information

Please provide the following information to help us better understand and support your needs.
Are you a Veteran?

Current Living Situation

Please provide details about your current housing. This information helps us understand your needs and determine the type of support or housing assistance that may be available.
Enter the number of months you’ve been living in this place.
Include information like who you live with, housing conditions, and any challenges you’re facing.

Income and Benefits Information

Please provide details about your current income sources, employment status, and any benefits you may be receiving. This information helps us determine eligibility for available programs and support services.
Public Benefits Currently Receiving

Veteran-Specific Information

Please provide details about your military service, including your service history, military branch, dates of service, and any specific benefits you’re requesting. This information helps us better understand your needs and connect you with appropriate veteran support programs.
MM slash DD slash YYYY

Assistance Requested

Please select or describe the type of support or services you need. This will help us connect you with the right resources.
Type of Assistance Needed

Needs Assessment

Please share more details about your health and support needs so we can connect you with the right services.
Health and Support Needs
Please provide any additional details about your healthcare, mental health, or other support needs.

Consent and Agreements

Please review and provide your consent for us to securely collect, use, and share your information with partner programs that help provide housing and support services. understand that my information will be used only to provide housing and supportive services and will be kept confidential as required by law.
Consent(Required)
MM slash DD slash YYYY
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