Register a Senior for HomeSafe

For Virginia homeowners and renters age 62 or older. Seniors, family members and social workers may all complete this form. It takes about 5 minutes.

1. Who is completing this form?

I am the seniorFamily / caregiverSocial worker / case manager

2. Senior's information

First name

Last name

Phone

Email (optional)

Age (must be 62+)

Best way to reach

Preferred language

How did you hear about HomeSafe?

3. Home and household

Street address

City

State

ZIP code

County / city (optional)

Own or rent?

People living in the home

5. Document collection

To confirm eligibility, a HomeSafe Home Specialist collects copies of the senior's proof of identity, proof of income and proof of residency. Please choose how you would like to provide them.

Option A1: Walk in at our Suffolk office100 Bosley Ave, Suffolk, VA 23434
Walk-in hours: Monday and Wednesday, 11:00 AM – 1:00 PM ET. First come, first served. Please allow about 1 hour.Option A2: Schedule an office appointment100 Bosley Ave, Suffolk, VA 23434
Monday – Friday, 1-hour appointments between 11:00 AM and 3:00 PM ET.Option B: In-home document collectionA HomeSafe Home Specialist visits the senior's home only to collect proof of identity, income and residency. Pick an available date and we will call to confirm the arrival time.

I confirm this information is accurate and I authorize Charity Care Group's HomeSafe program to contact the senior (and me, if I am submitting for them) about this application.

Questions? Call 757-226-9916 or email admin@charitycaregroup.org.

Register a senior for HomeSafe

1. Who is completing this form?

2. Senior's information

3. Home and household

4. What would help at home?

5. Document collection