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Interest Form

Apply Now!

Harmony House is always taking new clients. To begin the application process please complete the form below. One of our program managers will reach out with next steps.

Personal Information

First Name *

Last Name

Email Address *

Contact Number *

Application Date *

Month

Day

Year

Date of Birth *

Month

Day

Year

Demographic Details

What do you identify as?

Application Context

Are you applying for yourself or someone else? *MyselfSomeone Else

If applying for someone else, what is your relationship?

Housing Preferences

Do you understand that this is a shared living home and you will be in mostly shared spaces? *YesNo

Have you lived in shared housing before? *YesNo

How soon do you need housing, and what is your current living situation?

What type of room would you like to rent? *Private RoomSemi-Private Room

How many people do you need housing for?

How long do you anticipate living with us? *3 months6 months1 yearMore than 1 year

Financial Details

What is your monthly income?

Will you be responsible for paying your rent? *YesNo

If not, who will be paying your rent?

Transportation

Primary mode of transportation? *Personal CarPublic Transportation

Health & Medical Details

Are you currently taking any medications? If so, please list them

Do you have any medical conditions or health concerns we should be aware of?

Do you have any food or drug allergies?

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Contact Info

info@harmonyhouseinc.org

Harmony House

2024