Nobody Left Behind Solutions, LLC

INTAKE/ REFERRAL FORM

Contact our compassionate team for inquiries, consultations, or to discuss your care needs. We're here to support you and your loved ones.

Are you filling this form out for *

Yourself

A family Member

A patient/client (discharge planner, social worker, etc.)

Other

First Name

Last Name

Date of birth *

Gender *

Female

Male

Phone *

Email

Address

Street Address

City

State

Country

Postal code

Emergency Contact Name & Number *

Relationship to Emergency Contact *

Preferred Move-In Date *

ASAP

Within 2-3 weeks

within 30 days or more

Room Preference:

Double Occupancy

Single Room (subject to availability)

Do you require any special accommodations?

Yes

No

If yes, please explain:

Are you a: *

Veteran

Senior (Age 55+)

Both

Neither

Do you receive any support services (e.g., case management, disability benefits)?

Yes

No

If yes, please describe

Do you have any current mental health or physical conditions we should be aware of? *

yes

no

If Yes, Please decribe briefly

Are you able to live independently with minimal support? *

Yes

No

If No, please Explain

Are you currently taking medications? *

Yes

No

If yes, are you able to manage them independently?

Yes

No

Referrer Name, Organization Name, Number, Email, additional notes

Frequently Asked Questions

Answers To Commonly Questions

Who is eligible to live at Nobody Left Behind Solutions?

Our home is open to veterans, seniors, and individuals seeking a safe, stable, and supportive independent living environment. We welcome those who can live independently or with minimal assistance.

What’s included in the monthly stay?

Your stay includes: A fully furnished room (double or single upon request) 3 meals daily + snacks, companion support and wellness check-ins, Wi-Fi, Lights, water and laundry, Access to community areas and activities.

Do you accept individuals with disabilities or mental health needs? We are committed to providing compassionate care.

While we are not a medical facility, we do welcome residents with non-violent disabilities or mental health diagnoses who are stable and able to live in a shared community setting.

How do I apply or refer someone?

You can start the process by filling out our Resident Intake Form online. We also accept referrals from hospitals, VA centers, social workers, and families.

What's the cost and is there a minimum or maximum stay requirement?

Our independent living program starts at $200 per week, with a one-time, nonrefundable deposit of $500 required at move-in. We offer flexible month-to-month leasing with no long-term commitment. Residents are welcome to stay as long as they need, provided eligibility and a positive community environment are maintained.

Do you offer private rooms?

Yes. While most rooms are shared, private rooms are available upon request and subject to availability.

Is transportation included?

We do not currently offer transportation, but we can help coordinate services or provide local resource referrals as needed.

Can family members visit?

Absolutely. Family and loved ones are encouraged to visit during our designated visiting hours and be part of the resident’s support system

Contact Us

[email protected]

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