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EST. 2024

The Shepherd's Vineyard
Resident Screening Application

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Thank you for your interest in The Shepherd’s Vineyard. This application helps us determine whether our independent senior co-living housing may be a suitable fit.

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Applicants must be age 55 or older, cognitively aware, able to respond independently in an emergency, and able to manage daily living in an independent shared-home setting.


TSV provides housing only and does not provide medical care, personal care, meals, transportation, supervision, or case management. Complete applications are generally reviewed within 3–5 business days.

 

Applicants selected to move forward will be contacted to complete an in-person assessment. The residence address is provided only after final assessment acceptance.

Do you receive reliable monthly income
Yes
No

Monthly Income Sources (Select all that apply)

single choice
SSI
SSDI
Social Security Retirement
VA Benefits
Pension or Retirement Income
Other Reliable Monthly Income
Other Income Source, if applicable
Approximate Total Monthly Income

HEALTH & INDEPENDENCE

Are you able to move around independently, with or without a wheelchair or other mobility aid? *

Single choice
Yes
No

Are you able to independently manage bathing, dressing, toileting, eating, and other daily personal activities? *

Single choice
Yes
No

Can your personal care and support needs be managed without assistance or supervision from TSV staff or house mates? *

Single choice
Yes
No

Are you able to recognize and respond appropriately in an emergency without assistance from TSV staff? *

Single choice
Yes
No

Are you cognitively able to understand household rules and make your own decisions? *

Single choice
Yes
No

Do you currently receive assistance from an outside caregiver or support provider? If yes, please describe the type of assistance and usual schedule. *

single choice
Yes
No

BACKGROUND AND REFERRAL

ROOM PREFERENCE

Room selection indicates the applicant’s preference and does not guarantee availability.
Private (single occupancy)
Semi-Private (double occupancy)
Community (3-4 occupancy) *COMING SOON*

PRIVACY NOTICE

Information submitted through this application will be used only to review the applicant’s housing request, communicate about the application, and maintain TSV’s application records. TSV will not sell this information or use it for unrelated marketing.

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