First and Last Name*
Phone Number*
Email Address*
Date of Birth*
Gender* MaleFemaleNon-binaryPrefer not to say
Representative Name
Representative Organization
When do you need to be housed?*
Are you comfortable living in a shared housing environment?*
Please note: This program offers shared living only. Private rooms may be available starting at $900/per month.
YesNo
Monthly Income*
List all sources of income
Do you have a history of mental illness or currently live with a mental health condition?*
If yes, how would you describe the severity of your condition?
MildModerateSevereUnder Control
Diagnosis (if known)
Are you currently receiving any treatment or support services?
Do you have a disability or require any accommodations?*
If yes, please specify any accommodations or accessibility needs (e.g., wheelchair):
Are you an ex-offender?*
If yes, briefly explain the nature of the offense(s):
This information is used to better understand your background and determine how we can best support your placement. Your response will not automatically disqualify you.
Have you ever been convicted as a sex offender?*
(Answering “Yes” will not disqualify you.)
Do you consume tobacco?*
Do you consume alcohol?*
If approved, are you able to pay a $200 non-refundable deposit?*
Rent Payment Method – How do you typically pay your rent?* CashCash AppZelleOther
If Other, please specify:
Financial Readiness – If approved, will you be able to pay the $50 bed hold fee?*
Full Name*
Relationship*
Email
By submitting this form, you agree to:
Review process does not guarantee placement.
We may follow up for more info.
All info must be accurate.
Your data is kept confidential.
Typical response time is 5–10 business days.
You must follow all house rules if accepted.
This is not a landlord-tenant relationship.
Name of Patient/Legally Responsible Person*
Date Signed*
Electronic Signature Consent: By typing your name above, you confirm this acts as your legal electronic signature and certify that all provided information is true.