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Application Portal

Apply to Jacob's Home

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Complete the application below, or download the printable packet if you'd rather fill it out by hand. Everything you share stays private.

Prefer paper?

Download the full application packet to print, complete, and return by hand or email.

Download Packet

Applicant Information

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Current Living Situation

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Education Status

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Employment Status

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Independent Living Assessment

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There are no wrong answers — this helps us build your plan.

Budgeting & money management
Banking & credit
Cooking & meal planning
Cleaning & home care
Laundry
Transportation
Time management
Job search & keeping a job
School or training enrollment
Managing appointments & documents

Personal Goals

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Emergency Contact

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