Client Intake Form

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Our Home Independent Living
More than housing... A path to a better life

Use tab to navigate through the menu items.

First name

Last name

Birthday

Month

Day

Year

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Waht is your current living situation?

Homeless

Staying with family/friends

Transitional Housing

Other

When are you looking to move?

Date

Month

Day

Year

Are you able to live independently without 24-hour medical care?

Yes

No

What type of support are you looking for?

Stable Housing

Life-skills support

Employment resources

Community Resources

Other

Do not move to the application until you are contacted by a team member. This intake form is to make sure that you meet our criteria.

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