Individual Housing Application – Dignified Living Communities

Individual Housing Application

This application is for individuals seeking placement in a Dignified Living Communities residential home. Please complete all sections accurately to help us determine eligibility, placement readiness, and available housing options.

Personal Information

Full Name Date of Birth Phone Number Email Address Current Living Situation

Income & Benefits

Monthly Income Source Monthly Income Amount Upload Income Verification Upload ID

Placement Needs

Do you need a shared or private room? Do you need accessibility accommodations? If yes, please describe:

Health & Daily Living

Do you take medication? Do you need help with daily tasks? Mobility Status

Behavioral & Safety

Do you have any behaviors that may affect shared living? Are you on parole or court supervision? If yes, describe requirements:

Emergency Contact

Full Name Phone Relationship

Agreement & Signature

By signing below, you confirm that the information provided is accurate and that you agree to participate in a structured community living program if accepted.

Digital Signature (Type Full Name)

Thank you! Your application has been submitted. Our placement team will contact you with next steps.