application – Clarity Lives

Personal Information

Full Name

Date of Birth

Phone Number

Email Address

Do you have a valid Government ID?

Yes NO

Current Address

Guardian / Responsible Party Information

Name

Relationship

Phone Number

Email Address

Emergency Contacts

Name

Relationship

Phone

Secondary Contact (Optional)

Name

Relationship

Phone

5: Income Information

Are you a veteran?

Yes No

Monthly Income

Income/Funding Source(s) — check all that apply

Other Income Source

Medical Information

Primary Care Physician

Physician Phone

Do you have any allergies?

Yes No

Current Medications

Diagnosis / Disabilities

Mobility Needs

None - I walk independently Walker Wheelchair Other mobility aid

Dietary Needs or Restrictions

Behavioral & Support Needs

Do you have any behavioral concerns?

None Yes

Level of Supervision Required

Independent (I can manage my daily activities without supervision) Intermittent (I may need occasional check-ins or reminders) Constant (I need regular supervision throughout the day)

Housing Application Questions

What was the reason for leaving your current or most recent residence?

Have you ever been late on rent in the past 12 months? If so, please explain.

Have you ever received a notice to vacate, eviction filing, or lease violation?

May we contact your current and prior landlords for a reference?

Yes No

Can you confirm your current employer, position, and start date? (If applicable)

Do you have any additional sources of income you would like us to consider?

Can you provide your most recent pay stubs or proof of income?

Yes No

Are you able to pay the security deposit and first month's rent by the required date?

Yes No

Do you have a bank account for automatic withdrawal?

Yes No

Do you authorize us to proceed with employment, rental, and background verification?

Yes No

Is there anything else you would like us to consider with your application?

Placement Information & Preferences

Requested Move-In Date

Reason for Placement / Transition

Previous Living Situation

Family Home Group Home Independent Living Other

Hobbies / Interests

Daily Routine Preferences

Cultural or Religious Preferences

Consent & Certification

I certify that the information provided is accurate and complete to the best of my knowledge. I understand that providing false information may result in disqualification from the program. *

Housing Intake Application