Housing Inquiry Form

Please complete this inquiry form. Our team will review your information and contact you within two business days to discuss availability, answer questions, and determine whether Serenity at Pat's is the right fit for your housing needs.

Contact Information

Full Name *

Preferred Name

Phone Number *

Email Address

Preferred Contact Method *

Phone CallTextEmail

About You

Age *

Veteran Status *

YesNo

Applying for yourself? *

YesNo

Current Housing Situation

Why are you seeking housing?

Desired Move-In Date

Independent Living Screening

Are you able to live independently without daily personal care? *

YesNo

Do you require assistance with bathing, dressing, or medication administration? *

YesNo

Are you comfortable living in a shared home environment? *

YesNo

Income

Monthly Income Range *

Source of Income *

If other, please specify

Housing Preferences

Room Preference

Private RoomShared RoomNo Preference

Do you smoke?

YesNo

Do you have pets?

YesNo

Are you comfortable living in a smoke-free home?

YesNo

Are you comfortable sharing common areas with other residents?

YesNo

Accessibility

Do you use any mobility equipment? (cane, walker, wheelchair, etc.)

Are there accessibility features that would better support your daily living?

Transportation

What is your primary mode of transportation?

Referral Information

How did you hear about Serenity at Pat's?

If other, please specify

Additional Information

Is there anything you would like us to know about your housing needs?

Consent

I understand this form is a housing inquiry only and does not guarantee placement or admission. *

All inquiries are handled confidentially. We respond within 2 business days.

Contact Us

(813) 540-0793 813-602-3387
[email protected]
Serving Florida