Application
Housing Referral

Applicationinfo@gracefulwebsitedesigns.com2026-04-23T12:08:59+00:00

The Harmony Project

Application for Housing

The Harmony Program entry requirements: Program Participants will need to show proof of income, copy of state ID or Driver’s license. The Program participant must be independently mobile and cognitively aware.

Untitled

Name(Required)

First Last

Phone 1(Required)

Phone 2

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Social Security Number(Required)

Sex

Yes

No

Race (Individuals may select more than one category)(Required)

Hispanic or Latino:

American Indian or Alaska Native:

Black or African American:

Asian:

Native Hawaiian or Other Pacific Islander White:

Language: (Primarily Spoken)(Required)

English

Spanish

Other

If Other What is the Langange

Marital Status:(Required)

Never Married

Married

Divorced

Widowed

Separated

Living Situation: (Check only one)

Nursing Home

Parent/Guardian Home

Assistive Living

Family/Friends

Group Home

Transitional Housing

Own House

Homeless

Rent to Own

Renting House/Apartment ( )

Other

If other, Describe your living situation.

Source of Income(Required)

Income amount(Required)

Do you receive Food Stamps?(Required)

Yes

No

If yes, how much monthly

Have you been in the military?(Required)

Yes

No

Are you eligible for veteran's benefits?(Required)

Yes

No

Who referred you to this program?

Any Medical Diagnosis(Required)

If so, are you taking any medications?

Yes

No

If yes, what medications?

Any Mental Health Diagnosis?(Required)

Yes

No

If Yes, What’s the diagnosis?

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