Intake Form

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Intake Form

Housing Questionaire Form

Start your journey to independent living. Fill out this quick 3-step form and our coordinator will contact you within 24–48 hours.

Full name

Date of Birth

Phone Number

Email Address (Optional)

Gender Identity

Male Female Non-binary Prefer to self-describe

Which best describes you?

Veteran Elderly Adult needing affordable housing during a rough time Other

If Other, Please Explain

Do you have a service animal or emotional support animal?

Yes No

Do you have children that will need to live with you?

Yes No

If Yes: How many?

1 2 3 More than 3

Are you willing to live in a shared, drug- and alcohol-free environment?

Yes No

Are you independent? Can you care for yourself and manage daily routines?

Yes No

Do you need assistant with daily livning? If yes explain

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you have a support team (family, caseworker, etc.)?

Yes No

Do you have a Mental health Diagnosis?

Yes No

Are you currently taking any medications?

Yes No

If Yes, Please Explain

Have you ever been convicted of a crime?

Yes No

Are you currently on probation or parole?

Yes No

Tell us about yourself

Referral Agency

Preferred Move-In Timeframe

Monthly Income

How Do You Plan to Pay for Housing?

TODAY’S DATE

I confirm that the above information is accurate, and I understand someone will contact me within 48 hours.

Nevame Living is a veteran-owned housing initiative providing affordable, fully furnished independent living options for adults seeking stability and comfort.

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