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Thank you for reaching out. A member of our team will review your submission and reach out in 1–2 business days to discuss availability and next steps. We look forward to speaking with you.

Personal Information

Full Name *

Phone Number *

Email Address *

Age Range *

21–3031–4041–4950 or older

Are you a Veteran? *

YesNo

Preferred Method of Contact *

PhoneEmailText

Eligibility

Can you provide valid photo ID, SSN, and proof of income? *

YesNo

Room Interest *

Shared Room ($750–$850)Private Room ($1,150 — Limited Availability)

Income & Housing Budget

Income Sources — select all that apply *

SSISSDIEmploymentVA BenefitsRetirementPensionOther

Estimated Monthly Income

Monthly Housing Budget

Independent Living

Our homes are for independent adults. Program participants must be able to manage activities of daily living without medical or personal assistance.

Are you comfortable living independently? *

YesNo

Mobility *

I walk independentlyWalker or caneWheelchairNeed help with stairsOther

Substance Use

All of our homes are substance-free environments.

Are you currently sober? *

YesNo

Have you struggled with substance use in the past? *

YesNo

Mental Health & Wellness

For the safety of yourself and other program participants, it’s important to share your mental health and wellness status.

Have you ever been diagnosed with a mental health condition? *

YesNo

If yes — do you have a medication and treatment plan in place?

Are you currently receiving counseling or support services?

Background & Legal

Any current pending legal charges? If yes, briefly explain.

Have you ever been convicted of a violent or sexual offense? If yes, briefly explain.

Move-In & Support

Anticipated Move-In Timeframe *

As soon as possibleWithin two weeksWithin 30 days2–3 monthsOther

Case Worker / Agency / Organization *

How did you find out about Haven Point?

Additional Notes or Questions