Potential Neighbor Interest Form

Sender Name

Reply-To Email

example@example.com

This form has the capability of being saved and returned to at your convenience if you cannot complete it in one sitting.

Simply scroll to the bottom of the form and click the 'Save' button and follow the subsequent instructions.

Thank you!

Thank you for your interest in Amber Grace! Please complete all information below as accurately as possible and to the best of your knowledge. We acknowledge these forms simply offer a glimpse of who your candidate is. Your candidate offers unique qualities we desire to cultivate, grow, and champion. This interest form is simply one tool in the process. This interest form is NOT an application.

If you would prefer a digital PDF to type on your own computer or print to fill out by hand and return by mail, please email admissions@ambergrace.com to request this form be sent to you in a different format.

Age	Our Neighbors will range from 25-45 years of age upon admission.
Cognition	Amber Grace is designed to best serve individuals with a Mild Intellectual and Developmental Disability diagnosis (MID). The typical IQ range for these individuals is between 52-70. This is why we require a current (within the last 5 years) Psychological Evaluation as part of our application process. We also acknowledge an IQ test does not represent the full spectrum of a person's capabilities. If your applicant falls just outside this range of IQ, but you feel they meet all other compatibility profile benchmarks, please give reasons for asking for consideration when filling out your Potential Neighbor Interest Form. Neighbors must be able to clearly communicate their needs and comply with Community rules and policies. Our Neighbors must have an established legal guardian OR power of attorney established for health and financial other than themselves before admission.
Behavioral	The behavior of our Neighbors is of primary concern. Our Neighbors are capable of being engaged and attentive in a classroom setting without constant redirection that would be disruptive to others. Meltdowns and outbursts are considered disruptive behaviors. Our Neighbors must have no history of behavioral challenges nor have a history of harmful or aggressive behavior toward themselves or others.
Sleep	Normative sleep patterns are required, meaning individuals are capable of sleeping 8 hours through the night independently with no disruptions requiring support.
Physical	Upon admission our Neighbors are required to be ambulatory, continent of bowel and bladder, and able to perform activities of daily living (ADLs). Our Neighbors are able to safely function without direct supervision while inside our residential Community setting. While Amber Grace is a Community for adults, we do not partake of or allow the use of alcohol, recreational drugs, or nicotine substances on premises. At this time, we are unable to accommodate wheelchairs and other ambulatory aids nor provide skilled nursing care or continual medical supervision. At this time, we are not equipped to support individuals with significant vision and hearing challenges. Our Neighbors will have independence within the Community to spend time by themselves or with friends and will not always be in the direct presence of Staff members; therefore, it is important seizures be controlled by medication and occur at a frequency that will not require immediate medical attention or occur with a severity that will not endanger the Neighbor should they be alone or unaccompanied by a Staff member when the seizure occurs.
Relationships	While we encourage friendships and camaraderie among our Neighbors, we do not support romantic relationships. Neighbors must be willing and able to participate in group activities and engagement with others.
Spiritual	Amber Grace is a faith-based, Christ-centered Community; however, a statement of faith is not required for residency.
Other	To encourage family time for Neighbors and Staff, Amber Grace closes for the week of Easter, Thanksgiving, and Christmas. Specific dates will be included on our yearly calendar. Our Neighbors will need to arrange to spend these holidays with their loved ones. We are not designed to support Neighbors who drive themselves. Transportation support will be offered for all Neighbors. Our Community is not designed to accommodate individual Neighbor’s pets.

The ability to meet the above criteria is a requirement of all candidates. Candidates who do not meet these criteria cannot be considered at this time. Please continue filling out the information below if you feel your candidate meets the above criteria.

I have read the above Neighbor Compatibility Profile, and I agree my candidate is able to meet and comply with these requirements.

Signature*

Date*

MonthDayYear

Amber Grace is a privately and publicly funded 501(c)3 Community. According to our policy, we do not directly accept government financial aid. If possible, waivers and other forms of financial assistance may be self-directed to help offset the cost of living at Amber Grace. Using these avenues would be a direct relationship between the candidate’s responsible party and assistance entity.

If your official application is selected for consideration, you will be invited for an official on-site visit and interview. During this step of the process, we will ask you to complete a financial assessment with a third-party company. The heart of Amber Grace is to serve individuals from a wide range of incomes and backgrounds. Once entered into the Wait Pool, applying for financial assistance, if available, will be part of the admissions process.

* Please note, this Potential Neighbor Interest Form is NOT an official application.

Legal Name*

First NameMiddle NameLast Name

Preferred First Name

Birthdate*

MonthDayYear

Desired Start Date*

MonthDayYear

Age*

Sex*

Primary Diagnosis*

Secondary Diagnosis*

Home Address*

City*

State*

Zip Code*

Does the candidate currently reside at the home address?

YESNO

Does the candidate currently reside at the home address?*

YesNo

If NO, please describe*

Contact Name

Contact Name*

First NameLast Name

Relationship to Candidate*

Contact Phone*

Preferred Phone Number for contact purposes

Contact Email--IMPORTANT: This email will be used for all future email communications. Please make sure the main point of contact for the admissions process is the email listed here and typed correctly.*

example@example.com

Does the applicant have an appointed legal guardian OR power of attorney in place for health and financial for the applicant?*

YesNo

Legal Guardian Or Health POA Name (if different from contact information)

Relationship to Candidate

Legal Guardian Phone Number

Please enter a valid phone number.

Legal Guardian Email

example@example.com

Is the Contact Name or Legal Guardian listed above also the Responsible Party?*

YesNo

Responsible Party OR Financial POA Name (if different from Contact info)

Relationship to Candidate

Responsible Party Phone Number

Please enter a valid phone number.

Responsible Party Email

example@example.com

Please review the following items to demonstrate the needs and abilities of the candidate. To ensure the candidate’s needs are appropriately and adequately met, please respond to each item as honestly and accurately as possible. Please refer to the key below for a description of each assistance level. Place an “X” in the category that best describes the candidate. Please select only one option per task.

Independent	All tasks making up the activity are performed independently, safely, accurately, and without modification or assistive devices; tasks are completed within a reasonable time frame; Staff assistance typically not required
Prompts Needed	Only requires a small amount of help to accomplish the activity but may need Staff assistance to ensure safety and provide cues when needed; occasional Staff assistance may be required to set up items and/or monitor for safety
Assistance Required	Is able to perform 50% or less of the activity requiring Staff assistance to initiate or execute appropriately and safely; does not have the strength and/or cognitive ability to perform the task alone

Communication*

	Independent	Needs Prompts	Assistance Required
Ability to express emotions verbally
Ability to express wants and needs verbally
Ability to express pain and sickness verbally
Comprehends verbal communication
Can follow verbal instructions including 1-2 step directions
Can read and write a simple sentence

If Needs Prompts or Assistance Required is marked for any category above, please elaborate:*

Relational/Emotional*

	Independent	Needs Prompts	Assistance Required
Maintains friendships
Manages emotions without outbursts/meltdowns
Displays appropriate verbal and physical boundaries with others
Advocates for themself

If Needs Prompts or Assistance Required is marked for any category above, please elaborate:*

Is a romantic relationship a priority for you or your candidate?*

YESNO

Behavior/Physiological*

	Independent	Needs Prompts	Assistance Required
Can dress and get ready for the day
Can feed themselves
Can follow a schedule
Maintains attention and willingly participates in a classroom setting

If Needs Prompts or Assistance Required is marked for any category above, please elaborate:*

Behavior/Physiological (cont.)*

	YES	NO
Does the candidate currently partake in alcohol, recreational drugs, or nicotine consumption?
Is the candidate prone to elopement?
Does the candidate have a history of self-harm or harm to others?
Is learning to drive independently a goal or priority for you or your candidate?

If you responded YES to any of the questions in the table above, please elaborate or type NONE if you answered NO for all:*

Is the candidate ambulatory and able to move freely within their environment independently without the aid of a wheelchair or other assistive device?*

YesNo

Please explain any issues pertaining to sleeping through the night:*

Please list any repetitive behaviors and/or verbalizations:*

List all current medications and why they are prescribed:*

List all known allergies:*

List all chronic medical conditions such as seizure disorder, diabetes, etc.:*

List all current and past mental health conditions:*

Please initial to acknowledge you understand and would accept the following policies:

I understand technology (e.g.; cell phones, tablets, etc.) will be monitored and regulated by Amber Grace staff and policies

Initials* I understand technology (e.g.; cell phones, tablets, etc.) will be monitored and regulated by Amber Grace staff and policies

I understand that while friendships and camaraderie are encouraged among Neighbors, Amber Grace does not support or encourage romantic relationships.

Initials* I understand that while friendships and camaraderie are encouraged among Neighbors, Amber Grace does not support or encourage romantic relationships.

I understand while Amber Grace is a community for adults, the use of alcohol, recreational drugs, or nicotine substances is prohibited on premises.

Initials* I understand while Amber Grace is a community for adults, the use of alcohol, recreational drugs, or nicotine substances is prohibited on premises.

I understand a criminal background check will be part of the application process.

Initials* I understand a criminal background check will be part of the application process.

I understand I must make provisions for my candidate over the mandatory holiday leave dates.

Initials* I understand I must make provisions for my candidate over the mandatory holiday leave dates as the Amber Grace campus will be closed.

List what most interests you about your candidate being an Amber Grace Neighbor:*

How does your candidate feel about making a supported living community their home?*

Is there anything else you would like for us to know about the candidate? If your candidate falls outside the IQ range for mild IDD, please explain here why you would ask we give your candidate special consideration:*

Upon receipt of your Potential Neighbor Interest Packet, you will receive an email regarding next steps. We anticipate February 2026 as the earliest date Neighbors may begin moving into our Community.

We are excited you think we might be a good fit for your candidate, and we look forward to walking through the next steps with you.

Grateful for your time and support,

The Amber Grace Admissions Committeee

How did you hear about Amber Grace?*

Newsletter

Yes, subscribe me to this newsletter.

BEFORE YOU HIT SUBMIT! Please go to your email settings and add admissions@ambergrace.com as a trusted contact in your email addresses. This will prevent all future emails and notifications regarding the admissions process from going to your SPAM folder.

Also, please preview your form before submitting. It is imperitative the Contact Email listed on this form is accurate and spelled properly. Thank you!

Potential Neighbor Interest Form

Neighbor Compatibility Profile

Financial

Applicant Information

Medical