Fill out this Application | Better Living Homes

Name*

First Last

Date of Birth*

Phone*

Email*

If you don’t have an email address please put N/A

What's your Gender?*

Currently Experiencing Homelessness?*

Currently Incarcerated?*

Do you own any weapons?*

Firearm, knives, taser, tactical pen, etc

Do you have a history of violence?*

Is the client drug free and sober?*

Do you have a history of Alcohol Addiction?*

Do you have a history of Drug Addiction?*

If Yes, Please list all drugs you have used.

When is the last time you consumed Alcohol/Drugs?*

Is the client on prescription medication?*

If Yes, Please list all prescription medications currently being taken.

Have you ever been convicted of/or registered as a sex offender?*

Are you physically able to walk up & down stairs?*

What is the client's funding source?*

Other Funding Source:

Which best describes your monthly income?

How long does the client expect to be at Better Living Homes?*

What's your ultimate goal while living at Better Living Homes?

How did you hear about Better Living Homes?*

If Referral, please list the name of the Organization that referred you.

Please leave your information below if you are filling this form out on behalf of a client.

First Last

Email

Phone

Organization

Phone

This field is for validation purposes and should be left unchanged.

Apply by filling out this form below!