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Pre-Screener Form
Fill out the form carefully
Full Name
*
First Name
Middle Initial
Last Name
Age
*
Gender
*
Please Select
Male
Female
N/A
Last Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
example@example.com
Phone Number
*
Format: (000) 000-0000.
Do you currently have a stable source of income?
*
Yes
No
If yes, what type?
Monthly income amount
*
Are you currently employed?
*
Yes
No
Employer name
Are you able to pay a monthly program fee starting at $650/month, plus a small program entry fee?
*
Yes
No
Are you open to sharing a room with another adult?
*
Yes
No
Are you willing to follow strict house rules? ( No guests, no drugs, clean space, etc.)
*
Yes
No
Do you receive support from a caseworker, family member, or program?
*
Yes
No
Do you have any allergies, medical conditions, mental illness, or anything we should be aware of?
*
Yes
No
If yes, please explain
Do you currently take any medications?
*
Yes
No
Do you require any mobility or health-related accommodations?
*
Yes
No
If yes, explain
Have you ever been incarcerated? (This does not automatically disqualify you)
*
Yes
No
If yes, when, and what was your charge?
What are you hoping to gain from your next housing placement?
Are you planning to move in the home with a spouse?
Please Select
Yes
No
Are you planning to move in with a spouse?
Yes
No
Do you have children that will live with you?
*
Please Select
Yes
No
Will children live with you?
Yes
No
If yes, how old are they?
Preferred move in date or timeline
*
Anything else you would like us to know?
Submit
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