First Name (required)
Last Name (required)
Email (required)
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Phone (required)
Gender (required)
MaleFemalePrefer not to answer
What best describes you? (required)
VeteranElderlyOther
Can you live in a shared environment? (required)
YesNo
Are you comfortable living with people of different: (required)
GendersRace/EthnicitySexual Orientation
Do you have specific living space needs (allergies, mobility aids, etc)? (required)
If yes, specify (required) This field is required.
Preferred Rooming Arrangement: (required) —Please choose an option—PrivatePrivate SuiteSemi PrivateSemi Private Suite
Can you live with 24/7 surveillance in shared spaces? (required)
Do you have guaranteed income? (required)
Income Source(s): (required)
Monthly Income: (required)
Do you have a support system? (required)
If yes, describe (required) This field is required.
Do you have a Payee? (required)
Can you perform your own ADLs? (required)
What is your current ADL status? (required)
Do you require assistance with any ADLs? (required)
If yes, please select below: (required)
BATHINGDRESSINGAMBULATING Please select at least one option.
Note: We do not provide medical care or assistance with ADLs. All housing participants must be functionally independent.
Do you have a mental health diagnosis? (required)
If yes, list diagnosed condition(s): (required) This field is required.
Do you take medication(s)? (required)
What are your main goals for living in this housing program? (required)
How long do you anticipate staying with us? (required)
Do you participate in any support programs or case management?
Are you okay with shared responsibilities such as cleaning common areas and respecting quiet hours? (required)
How do you typically handle conflict with others? (required)
Do you have any pets? (required)
If yes, how many? (required) This field is required.
Are you okay living with pets (if the house permits them)? (required)
Do you have any current mental health diagnoses or concerns? (required)
Are you currently receiving mental health treatment? (required)
please describe provider or frequency (required) This field is required.
Do you have a history of substance use or recovery? (required)
please describe support needs or sobriety goals (required) This field is required.
Any physical health conditions we should be aware of? (required)
Have you ever been evicted or asked to leave a housing program? (required)
please explain (required) This field is required.
Do you have any criminal history we should be aware of? (required)
We do not automatically deny based on criminal history but need to assess compatibility and safety.
Are you currently on probation or parole? (required)
Are there any court orders or restrictions that affect your housing? (required)
How soon are you looking to move? (required)
Do you require assistance with any of the following?
Applying for SNAP benefitsJob PlacementApplying for VA benefitsClothing DonationsHealth Insurance EnrollmentMedication PickupMedication Reminders (No administering)Applying for SSI/SSDI
What does a healthy and respectful living environment look like to you?
What kind of support would help you succeed in this living situation?
Is there anything else you'd like us to know about you?
Aspire Housing & Care maintains a No-Tolerance Policy for violating house rules.
Can you reside in a shared environment with established house rules? (required)
Are you able to adhere to all the house rules associated with this Housing Program? (required)
Aspire Housing & Care offers a structured housing program with benefits and rules. Violating these rules may result in termination of your participation in the program. Future admission into the community will only be allowed upon approval from the owner/operator.
If you have any questions regarding our policies, feel free to ask.
Next Steps: A separate document outlining all program rules will be provided for review and signature. This can be sent via email or presented in person during your initial assessment.
Thank you for your time!
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8657 Elmwood Avenue Logansport, IN 46947
