Name

Email Address

Organization/Agency

Phone Number

Message

Applicant Full Name

Applicant Date of Birth

Applicant Phone Number (if applicable)

Current Living Situation Current Living SituationHomelessHospitalShelterWith family/friendGroup homeOther

How soon does the applicant need housing? How soon does the applicant need housing?Immediately (24–72 hours)Within 1 weekWithin 30 daysExploring future options

Please list their current monthly housing budget

Does the applicant receive income or benefits? Does the applicant receive income or benefits?SSI / SSDIEmploymentPensionVeterans benefitsOther (list)

List Other Forms of income

Does the applicant receive food stamps (SNAP)? Does the applicant receive food stamps (SNAP)?YesNo

Is the applicant sober, and willing to maintain sobriety in a sober home? Is the applicant sober, and willing to maintain sobriety in a sober home?YesNoIn treatmentUnknown

Is the applicant okay with a shared living environment? Is the applicant okay with a shared living environment?YesNo

Does the applicant require assistance with daily living skills (reminders, supervision, medication support, etc.)? If yes, please describe.

Does the applicant have any mental health diagnoses we should be aware of? (Example: Schizophrenia, bipolar disorder, depression, PTSD, MHMR needs, etc.) Does the applicant have any mental health diagnoses we should be aware of? (Example: Schizophrenia, bipolar disorder, depression, PTSD, MHMR needs, etc.)Yes (please list)NoUnknown

If yes, please list out the mental health diagnoses

Is the applicant prone to the following? Is the applicant prone to the following?Wandering / elopementAggressionSelf-harmHoardingMedication non-complianceNone of the above

Does the applicant have a legal guardian or power of attorney? Does the applicant have a legal guardian or power of attorney?Yes (provide contact info)No

If yes, please provide contact information

Does the applicant use mobility aids? Does the applicant use mobility aids?WalkerCaneWheelchairNone

ADL & CARE NEEDS — Please select all that apply: ADL & CARE NEEDS — Please select all that apply: Independent with all ADLs Needs reminders for ADLs Needs assistance with bathing or grooming Needs assistance with dressing Needs assistance with mobility Uses walker/cane/wheelchair Is incontinent (urinary) Is incontinent (bowel) Requires incontinence supplies Has a history of falls None of the above

What is the primary reason the applicant is seeking stable housing?

What outcome are you hoping Simon Collaborative Living can provide for this resident?

Additional notes or important information about the applicant: (Anything we should know for safety, compatibility, or care planning.)