Affordable Care Homes Pre-Screening
Please provide as much information as possible, and we will contact you within 24 hours. For immediate questions, please call (346) 771-5131.
NAME
First Name
Last Name
EMAIL ADDRESS
example@example.com
PHONE NUMBER
Please enter a valid phone number.
WHO ARE YOU APPLYING FOR?
Please Select
Myself
Family Member
Client (I am a Case/Social Worker or Sponsor)
Other
CLIENT'S NAME
CLIENT'S EMAIL
example@example.com
CLIENT'S BIRTHDATE
-
Month
-
Day
Year
Date
CLIENT'S PRIMARY LANGUAGE
MARITAL STATUS
Please Select
Married
Civil Union
Divorced
Separated
Widowed
Never Married
CLIENT'S CURRENT LIVING SITUATION
Homeless Shelter
Homeless (i.e. Street)
Hospital
Private Residence
Residential Care/Treatment
Womens/Family Shelter/Organization
Single Room Occupancy
Other
IF OTHER, PLEASE EXPLAIN
REASON FOR LEAVING
HAS THE CLIENT BEEN HOMELESS WITHIN THE LAST SIX MONTHS?
Yes
No
IS THE CLIENT AT RISK OF HOMELESSNESS?
Yes
No
WITHIN THE LAST 30 DAYS, HAS THE CLIENT LIVED IN A SHARED HOUSING SETTING?
WHAT TYPE OF HOUSING ARE YOU LOOKING FOR?
Veteran Housing
Transitional Housing (from Jail, etc.)
Elderly Care/Assisted Living
Special Needs Housing
Sober Housing
Independent Senior Living
Single Mother/Women Housing
Other
IF OTHER, PLEASE EXPLAIN
Are you okay with a shared bedroom?
Yes
No
DOES THE CLIENT HAVE A VIOLENT CRIMINAL RECORD? IF YES, PLEASE EXPLAIN AND ENTER PROBATION OFFIER'S NAME AND PHONE NUMBER
IS THE CLIENT ON PROBATION OR PAROLE?
Please Select
Yes, Probation
Yes, Parole
No
DOES THE CLIENT HAVE A PENDING COURT CASE?
Please Select
Yes
No
IS THE CLIENT ON PRESCRIPTION MEDICATION?
Please Select
Yes
No
DOES THE CLIENT HAVE MEDICAID?
Please Select
Active
Not Active
Pending
Unknown
No
WHAT DOES THE CLIENT NEEDS HELP WITH? (CHECK ALL THAT APPLY)
Housing
Paying Rent/Utilities
Securing Benefits
Medical Care
Shopping/Meal Prep
Money/Debt Management
Education
Mental Health Services
Opening A Bank Account
Hygiene
Substance Abuse
Taking Medication
Cleaning
Legal Assistance
Health and Wellness Services
Other
IF OTHER, PLEASE EXPLAIN:
CLIENT'S EMPLOYMENT STATUS
Employed Full-Time
Employed Part-Time
Unemployed
Unemployed - Looking for Work
WHICH BEST DESCRIBES THE CLIENT'S MONTHLY INCOME?
Please Select
$650 or less
$700 - $1000
$1000 - $1500
$1500+
WHAT IS THE CLIENT'S FUNDING SOURCE?
Please Select
SSDI
SSI
Voucher
Private Pay
Retirement
Salary
Other
IF OTHER INCOME SOURCE, PLEASE EXPLAIN:
NUMBER OF MINORS DEPENDENT ON INCOME:
DOES THE CLIENT RECEIVE STATE FOOD ASSISTANCE?
Please Select
Yes
No
IS THE CLIENT WORKING WITH AN AGENCY, CASE MANAGER, OR SPONSOR?
Please Select
Yes
No
IF SO, WHAT IS THEIR PHONE NUMBER OR CONTACT INFORMATION?
WHO REFERRED YOU?
Case Worker
Facebook
Google Search
Other
DOES THE CLIENT SMOKE?
Yes
No
WHAT DO YOU THINK IS THE CLIENT'S BIGGEST OR MOST CHALLENGING ISSUE?
WHAT SPECIFIC ASSISTANCE OR SUPPORT WOULD BEST HELP THE CLIENT REACH THEIR GOALS?
MOVE-IN DATE
-
Month
-
Day
Year
Approximate Date
ANY OTHER COMMENTS OR QUESTIONS?
Submit
Should be Empty: