ABOUT US
KCD Community Homes in Waukegan, Illinois provides a safe, structured, supportive living environment for women experiencing housing instability, for independent seniors seeking affordable housing, for women transitioning from detox, behavioral‑health treatment or medical discharge. We offer stability, accountability, and a clear weekly routine in a community‑focused setting.
Pre‑Screening Basic Information
Email or text the information listed below and our admissions team will contact you shortly to begin the pre‑screening process.
SECTION 1 — Applicant Information
Full Name:
Age:
Phone Number:
Email Address (optional):
SECTION 2 — Emergency Contacts
Emergency Contact #1 – Name & Phone:
Emergency Contact #2 – Name & Phone:
SECTION 3 — Move‑In Request
Requested Move‑In Date:
SECTION 4 — Referral Source
How did you find us?
Referred By:
Organization/Agency:
Contact Number (optional):
SECTION 5 — Pre‑Screening Questions
1. Are you currently sober, and how long?
Multiple Choice:
• Yes
• No
If yes, how long have you been sober?
If no, this program is not the right fit for you.
2. Do you require any medical or personal care assistance?
(Examples: medication administration, mobility assistance, daily personal care, medical supervision)
Multiple Choice:
• Yes
• No
If you answer Yes, this program is not the right fit for you.
3. For identity and background verification, can you provide a valid State ID or Social Security Number?
Multiple Choice:
• Yes, I can provide a State ID
• Yes, I can provide my Social Security Number
• No
If providing SS#: ________________________
We require at least one form of identification. If your answer is No, this program is not the right fit for you.
4. Have you been convicted of any criminal charges before?
Multiple Choice:
• Yes
• No
If yes, please list the charges:
5. What is your source of income for program payments?
Check one:
• Private Pay • Employment
• SSI • SSDI
• Pension • Alimony
• Other:
6. Can you pay the upfront fees to secure a bed?
(Must be paid before scheduling a move‑in date)
Upfront fees include:
• $100 Intake Fee (non‑refundable)
• $200 Security Deposit (refundable upon discharge)
Multiple Choice:
• Yes, I can pay the $300 total upfront fee
• No
7. Can you pay the program fee on your move‑in date?
Multiple Choice:
• Yes, I can pay $200 weekly
• Yes, I can pay $800 monthly
• No, I cannot pay on move‑in day
8. What payment method do you prefer?
• Cash
• Zelle
• Money Order
9. Do you agree to complete a mandatory drug test during intake/move‑in?
Multiple Choice:
• Yes
• No
SECTION 6 — Final Confirmation
I confirm that all information provided is true and accurate.
• Yes
• No
Email: kcdcommunityhomes@gmail.com
Mobile: 847-644-4332