Basic Information

First Name *

Last Name *

Date of birth *

Email *

Phone *

Emergency Contact *

(Name/Phone/Relationship)

Address

Street Address

City

State

Country

Postal Code

Best time to reach you: *

Do you identify as a member of the LGBTQ+ community?

Background & Living Situation

Where were you referred from?

(Agency, case manager, family member, self, etc.)

Are you transitioning from any of the following situations?

Do you currently have a case manager, social worker, or program contact?

If yes, please provide their name and contact info

Have you ever lived in shared housing before?

If yes, describe your experience:

Have you ever been evicted from a previous residence?

Have you ever been convicted of a felony?

Are you under probation?

If yes, please provide your PO contact details

Are you a registered sex offender?

Employment & Income

Are you currently employed?

What is your main source of income?

SSI

SSDI

Employement

VA Benefits

If not mentioned above, please classify below

What is your estimated monthly income?

(We may ask for confirmation — proof can be shown in person or sent electronically.)

Employer's name

If employed

Employer's address

Do you receive Food Stamps / EBT (SNAP benefits)?

Do you have identification?

Identification Card

Proof of income

Personal Habits & Lifestyle

Are you able to live independently without daily assistance?

Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?

How would you describe your cleanliness habits?

Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?

Do you smoke?

Do you have any pets?

Do you drink alcohol or use substances?

Medical & Mental Health

Are you currently taking any prescribed medications?

If yes, do you take it consistently?

Do you have any mental health diagnoses?

(If yes, please specify.)

Do you have any medical diagnoses?

(If yes, please specify)

When was the last time you saw a doctor?

Do you self-administer? *

Please note, we are not a medical facility and cannot administer medication.

Would you benefit from medication reminders? A staff member can remind you when it's time to take your medication.

Do you have any physical limitations or accessibility needs? *

If yes, please explain so we can do our best to accommodate you.

Substance Use & Recovery (if applicable)

Do you currently or have you ever used any illegal substances?

If Yes, What substance that you use? and how long are you clean?

What type of program did you attend?

If it is not listed, please specify:

What triggers or situations could cause you to relapse?

What coping strategies do you use to stay clean and focused?

Housing Preferences & Needs

What type of room are you looking for?

Shared Room

Private Room

Private Room with Bathroom

No Preference

When do you need housing? (Move-in date):

By agreeing below, I certify that the information provided is true and complete to the best of my knowledge. I understand that MT Legacy Foundation is a drug- and alcohol-free environment and that all residents must follow the program rules and policies to remain in good standing *

Yes

No

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📬 Contact Us

We’d love to hear from you. Whether you have questions about our programs, want to partner with us, or need assistance, our team is here to help.

📍 Address: Raleigh , NC & Surrounded Areas
📞 Phone: (919) 823-7677
📧 Email: [email protected]
🌐 Website: www.mtlegacyfoundation.com

Get In Touch

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