Residency Questionnaire

Step 1 of 5

20%

• Name*
  Thank-you for your interest in the Veterans Villages of New England Residency Initiative. Our Residency placement team would ask that you provide us feedback to understand how we can best serve your needs. Please provide the requested information to be registered for our Residency program.
  First Last

• Email
• Phone
• Your Current Zip Code

• Which Service Era where you a part ?
  • World War I
  • World War II
  • Korean Conflict
  • Vietnam Era
  • Persian Gulf War
  • Active
• Has Any of the following impacted your residency decisions ?
  • 2019 Novel Coronavirus
  • Housing Cost
  • Lack of Available Housing
• Has Any of the following impacted your residency decisions ?
  • 2019 Novel Coronavirus
  • Housing Cost
  • Lack of Available Housing

• Will your location require support of any physical challenge ?
  • Yes
  • No
• What Type of residency are you Interested in ?
  • Personal Residence
  • Independent Living
  • Home Care
  • Assisted Living
• Are you a Gold Star Family ?
  • Yes
  • No

• How many persons will be living with you including yourself ?
  • Myself Only
  • Myself plus 1 other person
  • Myself plus 2 other person
  • Myself plus 3 other person
• How many bedrooms will you need ?
  • Single Occupancy
  • Double Occupancy
  • Triple Occupancy
  • Quad Occupancy