Welcome Questionnaire
Please complete this form to begin the housing process.
Section 1: Applicant Information
Full Name:
*
Phone Number
*
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone Call
Text Message
Email
How did you hear about us?
Section 2: Current Housing Situation
Where are you currently staying?
Currently renting
Staying with family / friends
Homeless/Shelter
Transitional Housing
Hotel / motel
Other
How long have you been in this situation
Please Select
Less than 30 days
1-6 months
6-12 months
Over 1 year
Are you at risk of losing your current housing?
Yes
No
Section 3: Income and Benefits
Do you have any source of income?
*
Yes
No
If yes, what type?
*
SSI
SSDI
Wages
Other
Monthly amount?
*
Are you currently receiving any of the following?
*
Food stamps
Medicaid
Case Management
Rental Assistance
None
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Section 4: Household Preferences
Are you open to living in shared housing?
Yes
No
Do you have any concerns about sharing a space?
Do you have pets?
*
Yes
No
If yes, what kind?
Section 5: Personal Needs & Goals
What are your goals while living at Bridgeway Housing?
Stability
Employmnet
Recovery
Family reunification
Other
Are you currently working with a case manager or agency?
Yes
No
If yes, name/agency?
Do you have any barriers that might affect your housing (substance abuse, background, health?)
*
Yes
No
If yes, please briefly? (optional)
Section 6: Criminal Background
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
If yes, please briefly explain:
Are you currently on probation or parole?
*
Yes
No
If yes, name of supervising officer:
Substance Abuse History
Have you ever struggled with substance use or addiction?
*
Yes
No
Are you currently in recovery?
Yes
No
Please share any support or treatment services you are engaged in:
Court Involvement
Do you currently have any open legal cases, upcoming court dates, or active warrants?
*
Yes
No
If yes, please explain:
Section 7: Readiness & Availability
This information helps us understand your situation. It does not automatically disqualify you.
When would you be ready to move in?
*
Are you willing to follow house rules and participate in a shared-living environment?
*
Yes
No
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Emergency Contact
Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Acknowledgment
"I confirm that the information I have provided is true to the best of my knowledge. I understand this form is an interest form and does not guarantee housing."
Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: