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Safe & Supportive Shared Housing
All Utilities Included
Wellness Checks
Life Skills Support & Guidance
Referral Assistance for Community Services
Structured Environment with House Rules
Intake Form
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FAQs
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754-946-8200
Fort Lauderdale, Florida
Intake Form
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Intake Form
Name
Date of Birth
Email Address
Emergency Phone Number
Emergency Contact Name
Where do you currently reside? *
How soon do you need housing?
Immediately
Within a week
Within a month
Other
What is your current source of income?
Employment
SSI/SSDI
VA Benefits
Unemployment
Family Support
Other (please specify)
Are you currently employed?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Are you currently on probation or parole?
Yes
No
Recently completed
Do you have any medical conditions or special needs?
Yes
No
Do you require assistance with daily living needs?
Yes
No
Do you have any mental health or physical diagnoses?
Yes
No
Are you willing to live in a drug-free and alcohol-free environment?
Yes
No
Are you comfortable living in a shared space with other adults?
Yes
No
Consent
I confirm that the information I have provided is true and complete. I consent to its use for evaluating my eligibility for independent living housing.
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