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Your Next Chapter Starts Here….

This form is for individuals interested in occupying a space in our housing program. Submitting this form places you on a waitlist only and does not guarantee placement. Please be honest and answer questions to the best of your ability. Answering "yes" to any questions does not automatically disqualify you from consideration. 

Responses are used to help us understand your needs and determine the most appropriate placement, level of support, and program fit based on availability and safety considerations.

Birthday
Day
Month
Year
Are you 18 years or older?
Yes
No
Are you able to care for yourself independently?
Yes
No
Are you currently experiencing housing instability or homelessness?
Yes
No
Are you a veteran?
Yes
No
Current Housing Status
Desired Move-In Timeframe
Do you currently have any medical needs requiring 24/7 supervision and/or assistance?
Yes
No
Do you have any mental or medical health conditions that have resulted in psychiatric hospitalization within the past 12 months?
Yes
No
Prefer not to answer
Do you have any mobility limitations that we should be aware of?
Yes
No
Are you currently using, or have used within the last 30 days, any drugs or substances that may impact your ability to participate in a structured housing program?
Yes
No
Prefer not to answer
Do you have any active or past violent charges?
Yes
No
Are you currently on probation or parole?
Yes
No
Are you a registered sex offender?
Yes
No
Do you currently have any source of income?
Are you able to consistently pay the minimum $700 monthly program fee?
Preferred living environment
Preferred room type
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Date
Day
Month
Year
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