Housing Form

Before You Apply to Legacy Haven

We’re excited to welcome individuals ready for a fresh start. Please review these key requirements before applying:

Fully Furnished Housing

Enjoy a clean, move-in-ready space with included utilities, Wi-Fi, and on-site laundry.

Proof of Income Required

We accept SSI, SSDI, VA benefits, payee-managed funds, or private pay.

Independent Living Only

Applicants must be self-sufficient and capable of managing daily responsibilities.

Substance-Free & Structured

Legacy Haven is a sober environment with clear house rules to ensure community safety and respect.

Start fresh, live well. Submit your application today

1. What is your current housing status?

I am unhoused I am in a shelter I am staying with friends or family I have transitional housing I have permanent housing Other (please specify):

2. How long have you experienced housing instability?

Less than 1 month 1–6 months More than 6 months This is my first time experiencing homelessness Other (please specify):

3. Have you lived in transitional or supportive housing before?

Yes No Not sure Other (please specify):

4. Do you have a history of eviction?

Yes, within the last year Yes, more than a year ago No Other (please specify):

5. What is your current legal status?

I have active warrants I am on probation I am on parole I have no current legal involvement Other (please specify):

6. Have you ever been incarcerated?

Yes, within the past year Yes, more than a year ago No Other (please specify):

7. Are you a registered sex offender?

Yes No

8. Do you have any diagnosed medical conditions?

Yes No I’m not sure Other (please specify):

9. Are you currently taking any prescribed medications?

Yes No Sometimes Other (please specify):

10. Have you ever tested positive for a communicable or community-acquired disease?

Yes, tuberculosis (TB) Yes, hepatitis Yes, another condition No I don’t know Other (please specify):

11. Have you been diagnosed with a mental health condition?

Yes No I'm not sure Prefer not to say Other (please specify):

12. Do you have a history of substance use?

Yes, currently using Yes, in recovery Yes, but not currently using No Prefer not to say Other (please specify):

13. Do you currently have a healthcare provider?

I have a primary care provider I have a psychiatrist or therapist I do not have a healthcare provider Other (please specify):

14. What is your current source of income (if any)?

Employment (full-time) Employment (part-time) SSI SSDI VA benefits None Other (please specify):

15. Are you receiving any government assistance?

Food stamps (SNAP) Medicaid Housing vouchers TANF None Other (please specify):

16. Are you currently employed?

Yes, full-time Yes, part-time No, but actively seeking work No, and not seeking work Other (please specify):

17. Are you interested in any of the following services?

Job training or employment assistance Sobriety or recovery support Life skills coaching Mental health care Financial literacy Peer support or mentoring Other (please specify):

18. Are you a U.S. military veteran?

Yes No I'm not sure Other (please specify):

19. If yes, are you connected with VA or veteran services?

Yes No I'm not sure Other (please specify):

20. Do you have a DD214 or other proof of military service?

Yes No I need help obtaining it Not applicable

21. What are your goals while staying at Legacy Haven Housing?

Securing permanent housing Finding employment Stabilizing mental health Achieving sobriety Reuniting with family Building life skills Other (please specify):

22. Do you currently have any urgent personal needs we should be aware of?

Yes (please describe): No Prefer not to say

23. Are you able to follow structured house rules and curfews?

Yes No I'm not sure I would need accommodations Other (please specify):

24. Are you willing to live in a shared housing environment?

Yes No Prefer private space I'm open to discussing Other (please specify):

25. Are you willing to participate in case management or support services while in the program?

Yes No I'm not sure Other (please specify):

Submit