Step-by-Step Access to Housing Opportunities

NLF Legacy Independent Living Home Intake Form

Confidential Client Intake Information
(All information provided will remain confidential and used only for eligibility and support planning.)

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Personal Information

Name*

Date of Birth

Gender

Phone Number

Email Address

Social Security Number (last 4 digits)

Emergency Contact

Relationship

Phone Number

Current Living Situation

Current Address or Facility

Length of Stay

Reason for Leaving

Currently Homeless

Previous Transitional/Independent Program

Background Information

Justice-Impacted

Veteran

Probation/Parole Officer

Contact Number

Pending Court Cases

Currently Employed

Employer & Position

Health & Wellness

Medical Conditions/Disabilities

Prescribed Medications

List Medications

Primary Care Provider

Mental Health/Substance Use Treatment

Facility/Provider

Support System

Family or Community Support

Describe Your Support System

Interested in Mentorship Support

Goals & Readiness

Personal Goals for Joining the Program

Areas of Help (Employment, Education, Mental Health, Housing, Life Skills, Other)

Willing to Follow House Guidelines and Program Rules

Confidentiality Notice: All information shared is confidential and used only to determine program eligibility and support planning within NLF Legacy Independent Living Homes.

NLF Legacy Independent Living Home Waiting List Form

Confidential Client Information
(All information provided will remain strictly confidential and used only for eligibility and placement
purposes.)

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Personal Information

Name*

Date of Birth

Gender

Phone Number*

Email Address

Housing Interest

Desired Move-In Date

Preferred Home Type

Employment Status

Monthly Income

Please enter a number greater than or equal to 1.

Support & Background

Primary Reason for Applying

Current Support/Mentorship

Brief Summary of Your Current Situation

Emergency Contact

Name

Relationship

Phone Number

Referral Information (if applicable)

Referred By

Organization/Agency

Phone Number

Confidentiality Notice: All information submitted on this form is protected and will be used solely for the purpose of determining eligibility and placement within NLF Legacy Independent Living Homes. Your privacy and dignity are of the utmost importance to us.