Get added to waitlist

Get added to the waitlist

Independent Living Pre-Screening Questions

Basic Information

Income & Benefits

Do you have a steady source of income?

Yes No

Do you receive Food Stamps / EBT (SNAP benefits)?

Yes No

Do you have a working phone we can use to contact you?

Yes No

Independent Living Ability

Are you able to live independently without daily assistance?

Yes No

Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?

Yes No

Are you currently taking any prescribed medications?

Yes No

Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?

Yes No

Housing Preferences & Needs

What type of room are you looking for?

Shared Room Private Room No Preference

Do you understand this is a shared independent living program and you will have a roommate

Yes No

Do you have any physical disabilities or mobility concerns?

Yes No

Background Screening

Have you ever been evicted from a previous residence?

Yes No

Have you ever been convicted of a felony?

Yes No

Are you a registered sex offender?

Yes No

Lifestyle & House Rules

Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?

Yes No

Do you smoke?

Yes No

Do you have any pets?

Yes No

Get added to the waitlist

Get added to the waitlist

Basic Information

Income & Benefits

Independent Living Ability

Housing Preferences & Needs

Background Screening

Lifestyle & House Rules

Final Notes

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