Housing Request Form
Please fill out truthfully!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Birthday
-
Month
-
Day
Year
Date
What is your gender?
*
Male
Female
Have you applyied for housing at Natasha House?
*
Yes
No
What is your ethnicity?
*
Caucasian
African-American
Native American
Hispanic
Asian
Other
Please select all that applies to you in the PAST 12 MONTHS
*
Eviction
Foreclosure
Living With Family and Friends
Domestic Violence
Loss of Income
Serious Illness
Mental illness or Addiction
Other
Number of children you have custody of?
*
Where are you currently located at?
*
Have you been in a shelter? If so please list where below.
*
Did you call the Crisis Hotline?
*
Yes
No
Tell us why you are homeless or about to become homeless:
*
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Todays Date
*
-
Month
-
Day
Year
Date
How old are you?
*
Type of Household
*
Please Select
Single
Married
Other
Do you have your own Transportation?
Yes
No
Please list all children age & gender:
*
Have you ever served in the military?
Yes
No
Which Branch?
Please Select
Army
Air Force
Navy
Marine Corps
Coast Guard
Dates Served:
Were your referred to Natasha House by:
*
United Way First Call
Social Services
Mental Health Agency
Community Service Agency
Transitional Housing
Faith-Based Church
Self-Referral
Other
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Medical
Medical Conditions:
*
Epilepsy
Diabetic
Pregnant
Possible Pregnant
Seizures
Heart Condition
Other
None
Please list ALL prescribed medications:
*
Income
Employer
*
Wage/Salary (weekly,bi-weekly,1st &5th, monthly):
*
Please selected all that applies to you:
*
Child Support
Food Stamps
TANF
Disability
SSI
Unemployment
None
Please list the amount below:
*
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Next
Population Demographics
Please select all that applies to you:
*
Diagnosed with Mental Illness
Mental Retardation
Learning Disability
HIV/AIDS
Runaways/ Throwaways if under 18
Registered Sex Offender
Alcohol Abuse
Substance Abuse
Medical/Physical Disability
Recently Incarcerated (Past 12 Months)
None
I have filled out this form to the best of my ability, and I understand that someone will be with me within the next 48 hours of my status. I understand that if I don't hear back from someone then I am not eligible for the program.
Submit
Should be Empty: