Housing Request Form

PLEASE NOTE***

YOU MUST CALL THE NATASHA HOUSE AT 757-898-1993 TO BE PRE-SCREENED BEFORE PUTTING IN HOUSING REQUEST. IF A HOUSING REQUEST APPLICATION IS SUBMITTED AND YOU DID NOT CALL FIRST, YOUR APPLICATION WILL NOT BE ACCEPTED.

Did you call NATASHA House to be pre-screened before attempting to submit this housing request?*

YESNO

PLACE DATE YOU CALLED NATASHA HOUSE*

Date

Input your PRE-SCREENING number you received when you called:*

If you did not call NATASHA House first, STOP HERE and CALL 757-898-1993. Your housing request application WILL NOT BE ACCEPTED if you do not call first.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Birthday*

Date

What is your gender?*

MaleFemale

Have you applied for housing at Natasha House before?*

YesNo

If yes, when did you apply?

What is your ethnicity?*

Please select all that applies to you in the PAST 12 MONTHS*

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?*

YesNo

Tell us why you are homeless or about to become homeless:*