Your journey to Independence starts here

Name *

Address *

DOB *

Phone *

Email address *

Do you have a case manager? *

Yes
No

If yes, please provide phone number and email adress

Emergency Contact

Current Living Situation *

Living in car
Jail/Prison
Homeless
Hospital
Shared Housing Shelter
Living with family

Do you have any disabilities or special needs?

Yes
No

If yes, please explain.

Do you have any mental health conditions?

Yes
No

If yes, please describe your disabilities or special conditions.

Do you have any health conditions?

Yes
No

If yes, please describe your disabilities or special conditions.

Do you have any history of substance abuse?

Yes
No

If yes, when was the last time you used? What is your substance of choice?

Have you ever been convicted of a crime? (ANY)

Yes
No

If yes, please explain when were you convicted?

Are you currently on probation or parole? *

Yes
No

Are you receiving any of the following on a monthly basis?(check all that apply) *

SSI
SSDI
VA Benefits Pension
Employed
Assistance from a charity
Other

Please describe and provide income amounts.

Do you receive SNAP benefits (Food Stamps)?

Yes
No

Do you have health insurance?

Yes
No

When would you like to move in? *

As soon as possible
At a future date
Other

Leave this field empty

Ready to take the next step towards independent living? Genesis 126 LLC Independent Living Facility is here to support you. We understand that applying for residency can feel overwhelming, so we've designed a simple and supportive process. Let's explore how Genesis 126 can be your home.

Is Genesis 126 right for you?

Genesis 126 LLC Independent Living Facility is ideal for individuals seeking a supportive and comfortable environment. We welcome individuals in need of temporary or transitional housing. If you're looking for a place to thrive and maintain your independence, we encourage you to apply. Contact us at [[phonenumber]] or [[email]] with any questions you may have.

Addressing your concerns

We understand you might have concerns about applying for residency. Cost, the application process, and adjusting to a new environment are common hesitations. At Genesis 126, we're transparent about our fees and offer personalized support to ease your transition. We have options available, and we are willing to serve you. Call us today at (614-600-6362)

The Genesis 126 advantage

Our application process is designed to be as smooth and stress-free as possible. We offer clear guidance, answer all your questions, and provide support every step of the way. We'll help you gather the necessary information and ensure you feel comfortable and confident throughout the process. Choose Genesis 126 LLC Independent Living Facility for a hassle-free start to your independent living journey.