To begin the process with AE Legacy Solutions,

please take a moment to fill out our assessment form.

Completing this form will help us better understand your needs and how we can assist you. Thanks!

First Name *

Last Name *

Date of birth *

Phone *

Email *

Current Address: *

Desired Move-In Date: *

Length of Stay: *

1–3 months

3–6 months

6–12 months

12+ months

Preferred Room: *

Master Bedroom

Private Bedroom

Are you currently receiving any of the following? (Check all that apply) *

SSI/SSDI

Military Benefits

Employment Income

Others

Current Employer / Income Source: *

Monthly Income: *

Do you smoke? *

Do you drink alcohol or use drugs? *

Do you have any pending criminal charges? *

Have you ever been convicted of a felony *

Emergency Contact *

Relationship: *

Phone Number: *

Do you have any medical conditions we should be aware of for safety purposes? *

If yes, please specify: *

Any government valid ID

By providing all my details. I agreed to receive text messages and emails from AE Legacy Solutions LLC.