Prosper Haven Housing
Client Intake Questionnaire
1 Full Name
*
2 Date of Birth MMDDYYYY
*
/
Month
/
Day
Year
Date
4. Gender
*
Male
Female
5. Phone Number
*
Format: (000) 000-0000.
6. Email Address
*
example@example.com
7. Upload proof of ID
*
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8. Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact relationship
9. Currently homeless?
*
Yes
No
At risk of eviction
Other
10. Currently, Prosper Haven does not provide apartments or private housing solutions. We offer private and semi private rooms in a single family home. Do you understand that you will be living in a home with other individuals?
*
Yes
No
Have you ever lived in a shared housing environment before?
*
Yes
No
Based on your current income, what type of room are you interested in?
*
Shared Room starting at $750/mo
Private room starting at $1000/mo
Any available option
11. Do you have any current mental health diagnoses?
*
Yes
No
If yes please list all diagnoses or type NA
*
12. Are you currently receiving treatment or therapy?
*
Yes
No
N/A
13. Have you ever been hospitalized for mental health reasons?
*
Yes
No
If yes, please describe.
*
14. List all current medications.
15. Do you have any physical disabilities or mobility issues?
*
Yes
No
If yes, please describe.
16.Have you ever had issues with substance abuse?
*
Yes
No
17.Are you currently a treatment recovery program?
*
Yes
No
18. Do you currently use any substances?
*
Yes
No
If yes, please specify
Do you need help with substance abuse treatment or joining a recovery program?
*
Yes
No
19. Have you ever been convicted of a crime?
*
Yes
No
If yes, what were you charged for? List all charges and dates.
*
20. Are you currently on parole or probation?
*
Yes
No
If so, Probation/Parole Officer Name
*
Officer's Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
21. Are you a registered sex offender?
*
Yes
No
22. Are you a U.S. military veteran?
*
Yes
No
23. Do you currently recieve any government assistance?
*
Yes
No
Do you receive any government assistance? If yes, Select all that apply.
*
Yes
No
SSI
SSDI
Food Stamps
Section 8,VASH,Housing Voucher
TANF
Veteran benefits
Other
Do you work?
*
Yes
No
24 Amount of Guaranteed Monthly Income from SSI/SSDI/WAGES
*
When do you get paid
*
1st of the month
3rd of the month
3rd/4th Wednesday
Other
Please upload proof of Income
*
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25. Do you smoke?
*
Yes
No
26. Are you comfortable living in a space with others who may have mental health or substance recovery?
*
Yes
No
26. Are you comfortable sharing spaces (kitchen, bathroom, living and dining room) with others?
*
Yes
No
27. Do you have any allergies (food, animals, etc?)
*
Yes
No
If yes, list what you are allergic too?
*
28. Do you have children moving in with you?
*
Yes
No
If yes, what are their ages?
29. Why are you seeking housing with Prosper Haven?
*
Please list all areas you're willing to find housing
*
30. Is there anything else you would like us to know to better support you?
*
Do you have any hobbies or activities you love to do? (Cooking, cleaning, gardening, lawn care, etc)
How did you hear above Prosper Haven?
*
Shelter
Food bank
Case Manager
Word of mouth
Other
How soon are you looking to move in?
*
ASAP
Within a week
1-2 weeks
Next month
Other
How long do you need housing for?
Temporarily 1-3 months
Time to get on my feet 3-6 months
Permanently 6+ months
Other
If we are unable to provide housing, do you consent to Prosper Haven sharing your information with other independent living facilities that may have availability?
Yes
No
If accepted, I understand that my personal belongings may be searched when I move in or at any time while I am a member of Prosper Haven Housing. This includes bags, containers, and personal areas. Refusing a search may result in not being allowed to move in or being asked to leave the program.
Yes
No
I understand that by submitting this application, Prosper Haven Housing may conduct a background check to verify the information provided. I also understand that if any information on my application is found to be false, incomplete, or misleading, Prosper Haven Housing reserves the right to deny my application or revoke housing approval at any time.
Yes
No
Name of referring agent or business
Referring agent/ business contact information (phone and/ or email)
Please verify that you are human
*
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