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Preliminary Housing Intake Form

Building Hope. Creating Home. Changing Lives.

Fill Out The Preliminary Housing Form Below

Purpose

This is a preliminary website intake form used to gather basic housing and referral information and determine appropriate next steps. Submission does not guarantee acceptance or placement.

Privacy Notice

Do not submit Social Security numbers, medical records, medication lists, copies of identification, financial account information, or other sensitive documents through this website form.

APPLICANT INFORMATION

Full Legal Name

Date of Birth

Phone Number

May Legacy Haven Living contact you by telephone regarding this housing inquiry?

Yes

No

May Legacy Haven Living send text messages or leave a voicemail regarding this housing inquiry at the number provided?

Yes

No

Email Address

County of Last Residence

Current Address

Country/Region

Address

City

Zip / Postal code

If the applicant does not currently have a permanent address, the street-address portion may be left blank.

REFERRAL INFORMATION

Are you completing this form for yourself or referring someone else?

Representative/Referral Contact Name

Representative's Organization

Examples: VA program, hospital, behavioral health organization, social-service agency, faith-based organization, community organization.

Representative's Contact Number

Representative's Email Address

EMERGENCY CONTACT

Emergency Contact Name

Relationship to Applicant

Emergency Contact Phone Number

CURRENT HOUSING SITUATION

Where did you stay most recently?

What best describes your current living situation?

When is housing needed?

HOUSING PREFERENCES & REQUIREMENTS

Are you willing to consider a shared room?

Yes

No

Maybe / Would like more information

Do you currently smoke or use tobacco products?

Yes

No

Are there any current legal, supervision, or housing restrictions that could affect where you may reside?

Yes

No

Are you currently on probation or parole/community supervision?

Yes

No

Prefer to discuss during intake

Are you currently required to register on a state sex offender registry?

Yes

No

If Yes, placement eligibility will be reviewed based on applicable residency restrictions and the location of the residence.

INDEPENDENT LIVING & ACCOMODATIONS

Legacy Haven Living is intended to provide an independent living environment and is not a medical, assisted-living, or crisis-care facility.

Do you require a reasonable accommodation to participate in the application process or use the housing?

Yes

No

Is there anything about your housing needs that you would like us to discuss with you during the intake process?

Please do not include medical records or detailed medical information.

ALCHOHOL & DRUG-FREE COMMUNITY

Legacy Haven Living maintains an alcohol- and drug-free living environment. The possession, use, or distribution of prohibited drugs or alcohol on Legacy Haven Living property is prohibited and may constitute grounds for termination of participation and/or occupancy, subject to the applicable agreement and legal requirements.

Are you willing and able to comply with Legacy Haven Living's alcohol- and drug-free policy while participating in the program?

Yes

No

Required Applicant Acknowledgment* — I understand that Legacy Haven Living maintains an alcohol- and drug-free living environment and that violations of this policy may constitute grounds for termination of participation and/or occupancy, subject to the applicable agreement and legal requirements.

FUNDING INFORMATION

Approximate Monthly Income or Housing Funding Available

Optional. If no income or funding is currently available, enter 0.

If an organization or agency will be paying toward your housing, please provide the organization's name.

DOCUMENTATION

Identification and other required documentation may be requested later during the formal intake/admission process. Applicants should not upload Social Security cards, medical records, medication lists, government-issued identification, financial account information, or other sensitive documents through this website form.

ACKNOWLEDGEMENT & CONSENT

I certify that the information I have provided on this preliminary intake form is accurate to the best of my knowledge.

I understand that submitting this form does not guarantee acceptance or placement with Legacy Haven Living.

I understand that Legacy Haven Living provides an independent living environment and is not a medical, assisted-living, or crisis-care facility.

If accepted, I understand that I will be asked to review applicable program guidelines, house expectations, community standards, and the terms of my occupancy agreement before placement.

I understand that Legacy Haven Living maintains an alcohol- and drug-free living environment.

I authorize Legacy Haven Living to contact me regarding this housing inquiry using the contact preferences I selected above.

Applicant/Representative Full Name

Date

Preliminary Housing Intake Form

Interested in housing for yourself or a loved one?

Fill out our Preliminary Housing Intake Form.