Independent Living Application

INDEPENDENT LIVING APPLICATION

The Delux House
923 NE Woods Chapel Ste 182
Lee’s Summit, MO 64064
‪(816) 287-0163‬

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Page 1 – Basic Information – Step 1 of 6

First Name *

Last Name *

DOB *

Phone *

Email *

Current Address *

Address Line 1

Address Line 2

City

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Zip Code

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Current Living Situation *With family or friendsShelterTransitional housingOn the street/unshelteredOther

Currently Homeless? *

• Yes
• No

In Treatment? *

• Yes
• No

In goals Income

Veteran? *

• Yes
• No

Employed? *

• Yes
• No

Monthly Income *

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Referral Source *

• Self Referral
• Case Manager
• Church
• Hospital
• Treatment Center
• Reentry Program

Referral Contact Name *

Agency Name *

Referral Phone *

Referral Email *

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Why are you seeking housing? *

What goals are you working toward? *

Emergency Contact *

Special Accommodations Needed? *

• Yes
• No

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Photo ID *

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Income Verification *

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Referral Letter *

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Veteran Documentation (if applicable)

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