Application – Pillar of Peace

Getting to know you

Basic details so we can reach you and keep your file straight.

Applicant first name

Applicant last name

Date of assessment

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Email Address

Last known address

Your age

Your current living situation

There's no wrong answer here. We just need the real picture.

Current living situation

With family

Homeless

Shelter

Transitional housing

Other

Tell us where you're staying

Why are you looking for a new place to stay?

Our homes are for people living independently, so these questions are about your everyday routine.

Are you able to manage your daily routine on your own?

Yes

What do you need help with?

Are you able to clean and maintain your own living space?

Yes

Are you comfortable with shared living?

Yes

Are you able to cook or prepare your own meals?

Yes

Do you have a current source of income?

Yes

Where does your income come from?

Employment

SSI / SSDI

Family

Assistance

Other

Health and medications

This helps us know how to support you and what to do in an emergency.

Health information stays with our intake team. It is never shared with housemates.

Do you take prescribed medications?

Yes

Are you able to take your medications on your own?

Yes

Do you have any medical conditions we should know about?

Yes

Please describe

Are you currently receiving mental health support?

Yes

Substance use

Our homes are drug, alcohol and smoke free.

We ask everyone these questions. A yes does not automatically disqualify you — being honest here matters far more than the answer itself.

Are you willing to live in a drug, alcohol and smoke-free environment?

Yes

Have you been in a substance abuse treatment program?

Yes

When, and where?

House agreements

Shared living only works when everyone keeps to the same handful of rules. Here's what we'd ask of you.

Do you have a history of violent behavior or aggression?

Yes

Please explain

Follow a curfew, unless approved in advance

Yes

No visitors or overnight guests

Yes

Take part in household chores

Yes

Attend house meetings and check-ins

Yes

Be open to feedback from staff

Yes

What's next for you

I confirm the information above is true and complete to the best of my knowledge, and I understand that Pillar of Peace may contact my emergency contact or referral source as part of the review.

Type your full name as your signature