Louharmony housing program
Independent living program waitlist/intake form

Providing safe, stable and supportive housing for individuals in transition

Restoring lives through God’s love and grace.”

   •    “Safe shelter, guided by faith.”

   •    “Serving with compassion. Rebuilding with Christ.”


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Name

 *
Gender (sex at birth) *
Race *
Martial Status *
Date of Birth *
Phone number  *
Email *
Current Living Situation  *
Where were you referred from? *
Are you able to live Independently without daily assistance?
Being independent means the participant is able to manage their own daily activities without needing hands-on help from another person. This includes essential activities of daily living such as bathing dressing, Grooming eating using the bathroom and moving around safely an independent participant can take care of these needs on their own and does not require a regular physical assistance that they may still benefit from optional support, companionship, or community service .
 *
Do you currently receive help with daily activities? (cleaning, cooking, hygiene, etc.) *
Are you taking any prescribed medications? *
Do you have steady source of income? *
What is your estimated monthly income? ( we may ask for confirmation – proof can be shown in person or electronically.) *
Do you receive food stamps/EBT (snap benefits?) *
Do you have a working phone we can use to contact you? *
Do you have any children that will be with you? *
Do you have any difficulties accessing your medication’s? (cost, transportation, insurance, etc *
Will a shared room work for you? *
Does their participant have any disabilities that we should be aware of to provide appropriate support?
 A Disability is a physical or mental condition that may limit a person’s movements, sense, activities or ability to care for themselves. Disabilities can be visible or invisible, temporary or long-term. Example examples include mobility, impairments vision, or hearing loss, developmental or intellectual disability, chronic illness, mental health conditions, or learning disabilities.(if yes, please explain. If no, please type no.
 *
Have you ever been convicted of a felony? If yes please explain, if no type no.  *
Are you a registered sex offender or have they ever been required to register? 
 Please note: the answers to this questions are for program support, and planning purposes only responses will not determine eligibility or disqualifying the participant from the program
 *
Does the participant need case management services?( check all applicable.)  *
Required
How will participant pay for housing?
 Please note: award letter or proof of income will be required during intake. 
 *
Move in Date
 please enter the anticipated move-in date
 *
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Representatives name, Phone number, organization relationship (or title)
An Organization is any agency, Group or program that provides service or support to the participant? Examples include the veterans affairs, caseworkers, local mission programs, community health clinics, and other non-profits or faith base organizations in Valley of Arizona. 
 *
In addition to the above representative, does the participant have a support team? 
A support team the people who provide help, guidance, or assistance to the participant. This may include family, friends, a Payee, spouse, sponsor, or other trusted individuals included in the care of daily
 *
Are you willing to follow house rules?
(no drugs, alcohol, no unapproved guest, quiet hours, cleanliness.)
 *
Do you smoke? *
Do you have pets? *
Is there anything else you’ll like us to know? *
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