Resident Intake Form | Cozy Pathways

Applicant First Name

Applicant Last Name

Applicant Birthday

Month

Day

Year

Applicant Email Address

Phone Number

Current Living Situation

Shelter

Treatment Facility

With Family or Friends

Currently Unhoused

Room Selection

Shared Room (starting at $800/month)

Private Room (starting at $1,300/month)

First room available

Other

Total Monthly Income $

Are you able to provide the $200 non-refundable community fee at move-in?

Yes

No

Program Rules & Tenancy Requirements: Are you able to comply with all community housing rules and standard tenancy obligations, either independently or with the assistance of your own external support services?

Yes

No

Accommodation & Room Placement Preference

I require a ground-floor/first-floor room.

I prefer a ground-floor/first-floor room, if available.

I have no issues using stairs or upstairs rooms.

I require an accessible room with specific mobility features (e.g., zero-step entry, grab bars).

Behavioral History: Do you have any history of violence or property damage?

Yes

No

Background Check: Are you currently or ever been registered on any public sex offender registries?

Yes

No

How did you hear about Cozy Pathways Housing Program?

Disclaimer: By typing my name below, I certify that all answers are true. I authorize Cozy Pathways Housing Program to conduct a public safety screening and verify this information to ensure community safety. All admissions are at the sole discretion of management.

Applicant Digital Signature (Type Full Name)

Date Form Submitted