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🚨 LIMITED BEDS AVAILABLE — INDEPENDENT LIVING FOR SENIORS & VETERANS —

Kinsman of Neighbors

"Where Community Becomes Family"

📞 CALL NOW: (216) 354-1217

✔ Safe & Drug-Free

✔ Month-to-Month

✔ All Utilities Included

Apply for Independent Living

Intake Form

Kinsman Of Neighbors Intake Form

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Kinsman Of Neighbors Housing Program

Members Intake & Enrollment Application

Date of Intake: *

Participant Full Name *

Date of Birth: *

Age: *

Phone Number: *

Email address *

Gender: *

Male
Female
Non-binary
Prefer not to say

Emergency Contact Name: *

Relationship: *

Emergency Contact Phone: *

Current Living Situation *

Homeless
Couch surfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other

Referral Source (If Applicable)

Self
Agency
Case worker/State official
Hospital or Treatment Center
Family/Friend

Referring Contact Name (if any);

Referring Phone/Email (if any):

Brief Summary of Situation / Reason for Housing Need *

Medical & Mental Health History (List Below) *

Mental health diagnosis (if any), Substance use history (if any) *

Alcohol
Drugs
None

If yes, explain:

"Supervision Status" or "Program Support. -Are you currently working with a Case Manager? *

Yes
No

Are you a registered sex offender? *

Yes
No

If yes what Tier? *

(1)
(2)
(3)

Are you "Cross-Rated" (monitored by more than one agency/court)? *

Yes
No

Income Information - Do you have a source of income? *

Yes
No

Other:

Are you currently employed? *

Yes
No

Housing Preferences or Needs - Any disabilities or accommodations needed? *

Yes
No

If yes, explain:

Preferred Room Type: *

Shared Room
Private Room (if available)

Independent Living & Functionality Acknowledgment - Can you live independently and manage your Activities of Daily Living (ADLs) without assistance? *

Yes
No

If No – Please explain:

Do you currently have or need a home health care provider or outside support service? *

Yes
No

If yes – Agency Name (if applicable):

I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing. *

Agreed

Participant Initials: *

Date: *

Interests & Hobbies *

Program Agreement Preview *

I understand that if accepted, I must follow all house rules, expectations, and participate incase management or program-related check-ins.
I acknowledge that violating rules may result in a strike or dismissal from the program.

Applicant Declaration *

"I hereby certify that all information provided in this application is true and complete to the best of my knowledge. I understand that any false statements or omissions may result in my disqualification or termination of my membership agreement. I further acknowledge that this intake form does not guarantee placement and that my application is subject to review and approval by the Kinsman of Neighbors staff."

Participant Name: *

Participant Signature:

Date: *

Staff Name:

Signature:

Date:

Leave this field empty

Welcome to KINSMAN OF NEIGHBORS. Our Intake Form is your first step towards securing a safe, affordable, and supportive residential bed in our independent living community in Cleveland, Ohio. This form allows us to assess your financial eligibility and your commitment to our community's essential safety rules, including curfew and medication compliance. We welcome applications from prospective residents themselves, family members, or case workers who are seeking a dignified and structured environment for veterans, seniors, and re-entry individuals transitioning to self-directed living. Your journey towards independence and community starts here.

Funding Sources:

SSI , SSDI , Pension , Retirement ,Vouchers , Veterans Benefits

"Kinsman Of Neighbors is a verified service provider on Relink.org, ensuring our facility meets the professional standards required for client placements."