Consumer's Full Name
*
First Name
Last Name
Parent's name (if Consumer is a minor)
Address
City, State, Zip Code
city
Phone
Cell Phone
Email
Gender
Please Select
Female
Male
Age
What are your sources of income?
*
Please Select
Employment
SSI/SDI
Unemployment
Social Security
Child Support
TANF
Do you currently participate in a Section 8 Voucher Program?
Please Select
Yes
No
Is your voucher transferrable?
Please Select
Yes
No
Are you currently on a Section 8 Waiting List?
Please Select
Yes
No
If yes, how long have you been on the waiting list?
Do you participate in the RSVP (Rental Subsidy Voucher Program) through the San Diego Regional Center or in any other type of housing allowance program?
Please Select
Yes
No
How much do you currently pay for rent?
Where would you like to live?
What type of residence do you currently live in?
What kind of residence would you like to live in?
Total # of people who will be living with you:
What kind of Developmental Disability do you have?
*
Autism
Epilepsy
Cerebral Palsy
Developmentally Delayed
Other (Vision, Hearing, Etc)
Have you been dully diagnosed as a Ment Health Serv. Act(MHSA) consumer?
Please Select
Yes
No
What would you need to live comfortably in your new home?
Wheelchair accessibility
Adaptations for Deaf or Blind
First Floor Unit
Companion Animal / Service Dog
Other
If you selected other, please explain:
SDRC Case Worker's Name
*
SDRC Case Worker's Phone
*
ILS / SLS Worker's Name
ILS / SLS Worker's Phone
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