Housing Application
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Alias:
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
SS#
*
Place of Birth:
Which Housing Program are you applying to?
*
Milestone Place (Men and Women)
Reentry DBH Housing (Women Only)
Reentry Emergency Housing (Women Only)
Trinity Arms (Single Mothers Only)
Are you currently enrolled in another program?
*
YES
NO
If yes, explain.
*
Apartment Size?
*
One Bedroom
Two Bedroom
Three Bedroom
Gender
*
Male
Woman
Non-Binary
Other
Ethnicity
*
Hispanic or Latino
Non Hispanic or Latino
Marital Status
Single
Married
Divorced
Separated
US Citizen?
*
YES
NO
If no, what is your Immigration Status?
*
Current or Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
Is this address permanent or temporary?
Permanent
Temporary
Case Manager Contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Agency
*
Email
*
example@example.com
Homelessness
If homeless, please complete the following
How did you become homeless?
Is this your first time being homeless?
YES
NO
Date you became homeless
/
Month
/
Day
Year
Date
Reason for leaving prior housing?
Name of Shelter/Institution you've stayed?
Have you ever been evicted?
YES
NO
If yes, Date of eviction?
/
Month
/
Day
Year
Date
Information on Children
Only fill out if you are applying to Trinity Arms
Do you have children?
YES
NO
Are they living with you?
YES
NO
Is there contact with both children's parents?
YES
NO
Please Complete Information below on all of your children:
Childs Name
Date of Birth
School Attending
Any Disabilities?
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Do you have children that are not living with you?
YES
NO
If yes, why?
Do you have an open child abuse or neglect cases?
YES
NO
If yes, why and how long has your case been open?
Medical History
Current Heath Provider
*
Medicare
Medicaid
Charter Health Care
Blue Cross/Blue Shield
Other
Is the insurance in your name?
*
YES
NO
If no, please provide name of Primary Insurer:
If disabled, please list you and your family member's disabilities:
Mental Health History
Have you been hospitalized for an emotional or mental condition?
*
YES
NO
If yes, explain:
Have you received treatment and/or medication for emotional/mental condition?
*
YES
NO
If yes, explain:
Substance/Alcohol Abuse History
Ever used drugs or alcohol?
*
YES
NO
If yes, what type and how often?
Ever been treated for any addiction?
*
YES
NO
If yes, explain:
AA/NA/GA attendance?
*
YES
NO
If yes, where?
Do you have a sponsor?
*
YES
NO
Estimated last date of alcohol/drug use?
Military Service
Are you in the Active Military?
*
YES
NO
If yes, Branch of Military
Date of entrance and exit from military services?
Prisoner of War
*
YES
NO
Service related disability?
*
YES
NO
If yes, explain
Are you a Veteran?
*
YES
NO
If yes, date of discharge and location
Legal History
Have you been arrested before?
*
YES
NO
Is there currently a warrant out for your arrest?
*
YES
NO
Have you ever been convicted of a crime?
*
YES
NO
Have you ever served jail/prison time?
*
YES
NO
If yes to any questions above, please explain and list previous arrest record.
Are you on probation or parole?
*
YES
NO
If yes, give probation or parole officers name, phone number and the date it ends.
References
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship:
*
Completion of this application does not guarantee housing or supportive services.
Signature
*
Continue
Continue
Should be Empty: