Applicant Information
Help us understand your current residential setting, previous experience with cooperative living, and planned timeline for transitioning into our community.
Current Living Situation
Shared Home Experience
Transition & Move-In Date
Select one: Independent Apartment, Family Home, Shared Residential Care, Transitional Shelter, Temporary Lodging, or Other arrangement.
Prior shared or group home residency (Radio: Yes / No). If yes, document location name, municipality, and length of residency.
Provide primary reason for seeking new housing, along with your requested target move-in date (Date picker control).
Background and Legal History
Transparent disclosure allows our admissions committee to evaluate mutual community safety and provide supportive case planning.
Screening Authorizations
Explanation of Circumstances
Consent to Comprehensive Background Check (Radio: Yes / No). Required for all prospective adult housemates.
Required if answered Yes above: Detail specific charges, dates of resolution, sentencing or probationary status, and rehabilitation milestones.
Past Arrest or Criminal Conviction record (Radio: Yes / No). Past Incarceration record (Radio: Yes / No).
Past legal history is evaluated holistically and does not automatically disqualify an applicant from placement consideration.
Health Information
Accurate health information ensures our home environments are prepared to accommodate medical routines and wellness supports.
Medical Providers & Diagnoses
Medications & Allergies
Primary Care Physician or Clinic Name, Office Phone Number, and current documented medical or behavioral diagnoses.
Currently Prescribed Medications (Radio: Yes / No). Self-Administered without supervision (Radio: Yes / No). Comprehensive medication list input.
Active Mental Health Services: Specify whether applicant currently participates in therapy, counseling, or outpatient psychiatric care.
Known Allergies (Radio: Yes / No). Provide full descriptions of food, environmental, or pharmaceutical reactions.
We are committed to accessible, equitable living environments. Please indicate any physical, sensory, or cognitive accommodations needed.
Disability Documentation
Reasonable Accommodations
Does the applicant identify with a physical, intellectual, developmental, or sensory disability? (Radio: Yes / No).
Are environmental or architectural accommodations required? (Radio: Yes / No).
Provide clinical descriptions, official disability classifications, or specialized mobility considerations.
Examples: ground-floor bedroom, ramp access, zero-threshold shower, grab bars, visual alarms, service animal accommodations, or sensory modifications.
Functional Abilities (ADLs)
Rate the level of assistance required for each activity of daily living: Independent, Minimal Prompting, Partial Assistance, or Full Direct Support.
Personal Care ADLs
Mobility & Clinical Care
Household & Community
• Bathing & Personal Hygiene • Dressing & Wardrobe • Toileting & Continence Care
• Mobility & Ambulation • Medication Management • Communication & Speech Needs
• Meal Preparation & Cooking • Transportation & Travel • Money & Finance Management • Housekeeping & Shared Chores
Functional Notes & Adaptive Equipment
Enter explanatory notes regarding specific triggers, specialized assistive devices (walker, wheelchair, communication board), or daily routines.
Financial Information
Verifying income streams and coverage ensures sustainability and determines eligible rent structures and supportive allowances.
Financial Oversight & Income Sources
Coverage, Waivers & Case Management
Finance Manager Designation (Single-choice): Self-Managed, Representative Payee, Legal Conservator / Guardian, or Family Member.
Medicaid Status (Radio: Yes / No / Pending). If active or pending, provide State of Issue, Medicaid ID, and Case Number.
Select all active income sources: [ ] SSI, [ ] SSDI, [ ] Employment/Wages, [ ] Veterans Benefits, [ ] Medicaid/Waiver, [ ] Family/Personal Support, [ ] Pension/Retirement, [ ] Other.
Home & Community-Based Waiver (Radio: Yes / No, with waiver tier details). Assigned Case Manager (Radio: Yes / No, with Manager Name, Sponsoring Agency, and Phone).
Numeric entries: Estimated Gross Monthly Income ($) and Estimated Net Income Remaining After Personal Needs Allowance ($).
Private Medical Insurance (Radio: Yes / No, with Carrier Name, Policy Number, and Member ID).
Understanding daily vocational schedules and academic aspirations supports household rhythm and community participation.
Education Level & Programs
Employment Status
Highest Level Completed (Select one): Some High School, High School Diploma / GED, Some College, Associate Degree, Bachelor’s Degree, Graduate Degree, Vocational / Trade Certification, or Other.
Current Status (Select one): Full-Time, Part-Time, Supported / Sheltered Employment, Day Program / Workshop, Unemployed (Actively Seeking), Not Seeking Employment, or Retired.
Current Enrollment in Educational or Vocational Training Program (Radio: Yes / No). If yes, provide school/program name and weekly schedule.
Current Employer or Day Program Name, location, primary contact, and typical weekly hours.
Support Systems and Social History
A complete view of informal support circles and lived experience helps our team ensure trauma-informed, responsive care.
Primary Support Network
Substance Use History
Life Experience Indicators
Detail active support circles: family members, trusted mentors, church/faith communities, peer counselors, or social clubs.
Active or past substance use challenges (Radio: Yes / No). If yes, specify substances, frequency, sobriety duration, and treatment history.
Check all that apply: [ ] Homelessness or Housing Instability, [ ] Domestic Violence, [ ] Foster Care / Child Welfare System, [ ] Significant Trauma, [ ] None.
Goals and Preferences
Every ARC of Home household is built on mutual respect and shared interests. Share your personal aspirations and living environment expectations.
Personal Growth Goals
Shared Living Preferences & Referral
What do you hope to accomplish during your residency? (e.g. greater independence, employment stability, community connection, life skills development).
Preferences or sensitivities regarding roommates, pets, noise levels, shared chores, or visiting guests.
Describe individual hobbies, cooking interests, wellness routines, and favorite weekend activities.
Primary Referral Source (Select one): Case Manager, Family / Friend, Social Worker, Online Search, Hospital / Healthcare Provider, or Other.
