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Application Page
General Information (Nice to meet you!)
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First name
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Last name
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Phone
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Email
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Birthday
Month
Day
Year
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Please select which demographic(s) describe you.
Over 62
Under 62
Honorably discharged veteran
Returning citizen
Have life-limiting health condition(s)
Currently homeless
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Please give us a brief (1-2 sentence) description of your current living situation.
General Health Questions
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Do you require palliative care?
What medication(s) are you taking?
Tell us about: Vision if not 100%
Tell us about: Hearing if not 100%
Tell us about: Dental needs if you have them
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Do you struggle with any of the following?
Difficulty communicating
Disorientation with time / place
Disruptive agitation
Hallucinations
None
Other
Your Living Requirements
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Mobility
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Do you use a wheelchair?
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Bathing
If you require minor assistance with the bath / shower, please select:
Getting in/out of the bathtub
Getting in/out of the shower
Washing hard to reach places
Turning taps on/off
Generalized supervision
Other
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Dressing
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Grooming & Hygiene
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Eating
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Bladder / Bowel Control
Do you have difficulty with any of the following?
Raising toilet seat
Difficulty with pant buttons, zippers
Mechanical aid assistance (e.g. catheter)
Other
Living With Us
Please acknowledge that you are able to:
Grocery shop and/or feed yourself independently
Maintain a generally tidy living space
Share common areas with others, including primary entrance, kitchen, bathrooms, and backyard
Arrange your own transportation for independent daily activities
Use a telephone proficiently enough to answer calls or text messages/email
Do your own laundry with access to a washer and dryer
Smoke only outside
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Will you need a parking space?
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Your commitment to us is on a month-by-month basis. However, do you have a timeframe in mind for how long you plan to stay?
Financial Profile
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Please select your applicable benefit(s):
Social security (SSI)
Disability (SSDI)
Veteran disability
Veteran pension
None
Other
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Who primarily handles your financials?
You made it to the end!
Is there anything else that you would like for us to know?
After you click "Submit", we will give you a phone call. Speak to you soon!
Submit
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