Apply - Welcome

Ezrat Chaim provides transitional, independent housing to young adults over age 18 who are actively working or in school, yet struggling with their families or society. Self-referrals and referrals from community leaders or organizations, Social Services, and health or government agencies are accepted. Our homes are Shomer Shabbos, fully kosher, and drug-free.

Residents are required to have their own therapist and attend weekly sessions, and must also participate in our life skills workshops. Each resident is assigned a case manager/housing worker during their stay.

Please submit the application form and an intake worker will be in contact for an interview. Submitting an application does not commit Ezrat Chaim to accepting you. All applicants must have a personal interview with our intake staff before being accepted.

Name

First Last

Preferred Name

Gender(Required)

Email(Required)

Date of Birth

Address

Street Address City Country

Phone

Status(Required)

First Language(Required)

Second Language

Describe you current living condition(Required)

Other- Living Conditions

Income/Employment/Education

Highest level of education completed

Are you currently attending school?

If yes, what is the name of the school:

Are you currently employed?

What is the name of your employer:

Are you currently enrolled in school or a vocational training program?

If yes, which school or vocational program?

What would be your source of income for paying rent in transitional housing?

Please explain other source of payment

Health

Do you have any physical health concerns?

Yes

Please describe your physical health concerns

Do you have any mental health concerns?

Yes

Please describe your mental health concerns

Do you have any allergies?

Yes

Please list your allergies

Social Support

What does your social support look like?

Are you currently receiving support (financial, therapeutic, or other) from community or government agencies?

Yes

If yes, please list support:

Other

How do you think this program will benefit you?

Is there anything else you would like us to know?

Emergency Information:

Emergency contact’s name

Relationship to your emergency contact

Telephone of emergency contact

Alt phone of contact name

Email of emergency contact

CAPTCHA

Ezrat Chaim is a non-profit organization recognized by the Israeli government and affiliated with a U.S. 501c3.

Creating new paths and transforming futures.