Pre-Application

Home > Pre-Application

Pre-Application

Please note that this is an application for the wait list and does not constitute acceptance into this program housing. Once your application has been received, staff will reach out to you to learn more about your situation. Thank you!

Who are you applying for?

Myself A Client Family Member Other

Client's Gender

Male Female

First Name

Last Name

Rep's Name of Organization

Representative Name

Phone Number

Do we have permission to leave a message/text on the number provided?

Yes No

What's your current living situation?

Living with a friend Living in a car Living in a shelter Living on the street None of these above, I am still living in my home

What type of housing are you or the client applying for?

Senior Living Care Facility Veterans Housing Independent Senior Living Sober Home Housing Shared Living Space

How will you or the client pay?

SSI/SSDI Self funding Agency funding Others

What Is The Client's Current Emplyment Status?

Employed-Full Time Employed-Part Time Not Employed

How did you hear about us?

Is there anything else you would like to share with us?

Our Mission is to provide affordable and quality all-inclusive living environments to all of those who are in need!

Quick Links

About Us
Pre-Application
Our Serviceas
Donate

Keep in Touch

972-904-8621
customercare@calmcarehealthyliving.com