Elevare Housing Intake Form
Independent living with shared spaces.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Gender
Male
Female
Are you currently homeless or at risk of homelessness? (Yes/No)
What city are you currently in?
What’s your current living situation? (shelter, street, with family, hospital, etc.)
Do you receive verifiable income? (Check all that apply)
SSI
SSDI
VA Benefits
Income from Job
Other
Total Monthly Income?
Referred By (if submitted by a caseworker)
First Name
Last Name
Agency/Organization
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you okay with shared living?
Yes
No
Do you have any physical disabilities or medical concerns?
Yes
No
If yes, explain
Pets?
Yes
No
Which best describes you?
Senior 55+
Veteran
Domestic Violence Survivor
Transitioning from Homelessness
Individual seeking affordable shared living
Other
What outcomes are you hoping to achieve?
Is there anything else you would like us to know?
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: