Pre-Screen Application

THE IMPROVEMENT ASSOCIATION'S

PRE-SCREEN/FRONT DOOR ASSESMENT
Date*

MonthDayYear
Date
PLEASE CHECK THE SERVICE REQUESTED BELOW*

Workforce Development InitiativeHousingSenior ServicesUtility AssistanceRental Assistance (arrears)Other
HOUSEHOLD INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the mailing address is different from the above address, please enter Mailing Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Date of Birth *

MonthDayYear
Date
Number of other household members *
Age(s) of other household members
Household Gross Income in last 30 days*
Source of all Household Income*

Wages (Employer)SSISSDITANFSNAP (Food Stamps)Other
If other, please explain
If employed, please list employer(s)
Select type of health insurance*

PrivateMedicaidMedicareVADisability InsuranceNoneOther
Are you a Veteran*

YesNo
Are you currently enrolled in any Improvement Association Programs? If so, please indicate by checking the appropriate box below:*

Head StartHousingWorkforce DevelopmentParents as Teachers (PAT)Project DiscoverySaint Paul's Child Development (Daycare)None
** IF APPLYING FOR THE WORKFORCE DEVELOPMENT INITIATIVE PLEASE COMPLETE SECTIONS A & C****

SECTION A
Are you currently employed?

YesNo
If employed,

Full TimePart TimePRNOther
If employed, Please list name of employer
Are you currently receiving TANF (Temporary Assistance for Needy Families)?

YesNo
If yes, monthly benefit amount
Have you ever received TANF benefits?

YesNo
If yes, when is the last time benefits were received?
Do you have a High School Diploma

YesNo
Do you have a GED?

YesNo
Do you have a College Degree?

YesNo
If yes, please indicate type of Degree and Major
Do you have reliable transportation?

YesNo
Please list your educational goals
Please list your career goals
*** IF NOT APPLYING FOR HOUSING OR UTILITY ASSISTANCE PLEASE SKIP TO SECTION C***

SECTION B
Are you currently safe where you are staying?

YesNo
If no, please explain
Where did you stay last night?

Emergency shelter, including hotel or motel voucher paid for by a social service or charitable organization.Place not meant for human habitation (street, car, park, etc.)Shelter or place not meant for human habitation, exiting a Psychiatric or other substance abuse facilityTransitional housing for homeless personsRoom, apartment or house that you rentApartment of house that you ownIn a friend's or family member's room, apartment or house in subsidized housingIn a friend's or family member's room, apartment of houseHotel or motel paid for without emergency shelter voucher, social service or charitable organizationOther
If staying in a motel, please indicate who is paying below:

I am paying for my own hotel/motel staySomeone else is paying for my hotel/motel stay
How long have you stayed in the facility selected?

One week or lessMore than one week, but less than one monthMore than three months, but less than one yearOne to three monthsOne year or longer
What type of assistance are you in need of? (select all that apply)

Rent Arrears (behind in rent)1st month's rent and/or security depositUtilitiesRental InformationHelp finding housingLegal assistanceLandlord mediationBudgeting assistanceOther
Are you behind in rent due to the Covid-19 Pandemic?

YesNo
Why do you need to leave? (select all that apply)

Received an Eviction Notice (Court order)Non-payment of rent/past due rentFailure to pay rent, due to issues with incomeNon-payment of utilities or shut off noticeFriend/Family member threatened with an eviction (asked to leave)Location condemnedThreat of abuse by partner, family member, or otherDischarge or service being terminatedOther lease violationsOther
If being evicted, is your Eviction Notice Court Ordered? (Unlawful Detainer)

YesNo
If yes, when is your court date and Locality?
When do you need to leave or how many nights can you stay?

TodayNext 2 to 4 daysWithin next 7 daysWithin next 14 daysWithin next 3 weeksWithin next 30 daysWithin next 2 monthsOther
How many times have you been homeless?

First time homeless1-2 times in the past4 times in past 3 years2 Years or more: Long TermOther
How many times have you moved in the last 12 months?

None1-2 times in past 12 months1-2 times in last 6 months2 or more times last 60 daysOther
Has any income been received in the last 3 months?

YesNo
Is a member or the Household pregnant?

YesNo
Is current housing jeopardizing another household housing stability?

YesNo
How much is current rent?
Has the Head of Household previously experienced homelessness as an adult?

YesNo
Does one or more members of the household have a physical disability or chronic health condition? (documentation required)

YesNo
Does one or more members of the household have a mental health or substance abuse issue?

YesNo
Have one or more members of the household had previous involvement with child welfare including foster care? (documentation required)

YesNo
Did the head of household "age out" of foster care in the past 12 months?

YesNo
Did the head of household previously reside in an institutional setting (treatment facility, jail, prison, psychiatric hospital, etc.)? (documentation required)

YesNo
Is the head of household experiencing domestic violence?

YesNo
How many prior evictions does the Head of Household have?
What type of credit does the Head of Household have?

GoodFairPoorNo Credit
Does the Head of household owe rental arrears from previous eviction (separate from current situation)?

YesNo
Does the head of household have more than one misdemeanor conviction?

YesNo
Does the head of household have a past felony conviction within the past 10 years?

YesNo
Does the head of household have more than one past felony conviction?

YesNo
Have you experienced a loss of Income and/or Increased COVID Related Expenses?

YesNo
If Yes, the Household has experienced a negative financial impact (directly or indirectly) due to Covid-19 or is receiving unemployment benefits. Please select the reason(s) for loss of income and/or increased Covid related expenses below (select all the apply):
Laid OffPlace ofemployment has closedReduction inhours of workMust stay home tocare for children due to closure of day care and/or schoolReduction or eliminationof child or spousal supportNot able to workand/or missed hours due to contracting Covid-19ReceivingUnemploymentUnable to findwork due to Covid -19Unwilling orunable to participate in previous employment due to high risk of severe illnessfrom Covid-19You have had anincrease in expenses due to Covid-19, i.e. child care, medical bills, etc.
If applicable: Covid Impact Narrative (Required): Describe loss of income and/or increased expensesdue to Coronavirus pandemic, including circumstance(s) resulting in a negative financial impact for the household.
***SECTION C ***
Please Explain Your Crisis below if not covid related:*
I certify that the information contained in this pre-application is true and complete. I understand that false information may be grounds for not processing this application or immediate termination of my program(s) participation at any point in the future if I am accepted into the program. I authorize the verification of any or all information listed above. I also understand that submission and/or completion of this application does not guarantee approval and/or acceptance into any program.
Signature*

Clear
Date*

MonthDayYear
Date
How did you hear about The Improvement Association? If referred, please indicate referral source.
Please upload any supporting documentation.

Browse Files

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***Please note that proof of income, a copy of the utility bill, rent ledger, eviction notice, pay or quit, or whichever may apply and a copy of the lease agreement will be required. You may attach it by uploading above.
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THE IMPROVEMENT ASSOCIATION'S