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Participant Intake Form

Welcome to Living Independently Housing Program!
We’re excited to help you take the next step toward safe, supportive, and independent shared living. Please complete the intake form below so we can better understand your needs and determine eligibility for our housing program.

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Apply here

Birthday
Month
Day
Year
Are you a US citizen?
Are you able to provide a US ID?
Are you able to pay the participation fee?
Are you able to pay the one-time holding fee of $300.00
Preferred Method of Contact: (Please choose all that apply)
How did you hear about us?
What are you interested in? (Check all that apply)
Living Independently Housing Program is committed to providing the highest quality living spaces for seniors, veterans, and individuals transitioning. Our team of professionals ensures that each home is fully equipped and tailored to meet the unique needs of our participants. Contact us now to learn more about our offerings.

Call us today on 1-800-575-5928

Email: info@living-independently.org

© 2035 by Living Independently Home Care, LLC-owner/operator

Website creator: LaManda Goodrich

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