Pre-screening Application

INDEPENDENT LIVING PRE-SCREENING APPLICATION

Please answer any and all questions as truthfully and to the best of your ability. Any anwser given is not to disquailfy you, but it is to help us better place you. Apply now as beds fill fast.

Full Name *

Date of birth *

Gender *

Male
Female

Current Address *

Street Address

Street Address line 2

City *

State/ Province *

Postal/ Zip Code *

Phone Number *

Email (if applicable) *

Referral Source: (Agency, Case Manager, Family Member, Self) *

Income and Benefits

Current Source of Income: *

SSI
SSDI
Employment
VA benefits
Other