Jones Second Chance Housing: Interest Form

Jones Second Chance Housing (Men’s Independent Living Program)

Structured Independent Shared Housing for Adult Men in Transition
⚠️ Please Read Before Completing This Application

Jones Second Chance Housing is an independent shared living program designed for adult men only.

If you are a woman seeking housing, please apply to Jones Haven for Women:
https://form.jotform.com/252935101060041

If you are a woman with children seeking housing, please apply to Jones Haven for Women & Children:
https://form.jotform.com/260314691869062

Applications submitted for the incorrect program will be redirected.
Section 1: Personal Information
Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Phone Number (Primary)*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Emergency Contact - Full Name*
Emergency Contact - Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Section 2: Current Situation
Currently IncarceratedRecently ReleasedOther
Date of Release (if applicable)

MonthDayYear
Date
YesNo
ShelterHomeCouch-to-CouchStreet/HomelessTransitional HousingOther
Section 3: Referral Information
YesNo
If yes, please provide the name and contact information of your referral.
Please provide the name of referring organization (if applicable).
Section 4: Support & Income
YesNo
If yes, please provide their name and contact information:
YesNo
If yes, please list the type(s) of income or assistance you receive:
EmployedSeeking WorkNot currently seeking
Section 5: Housing Needs
YesNoMaybe
If maybe, please explain:
YesNo
If yes, please describe:
YesNo
If yes, would you like to share any details that may help us better understand your background or support your transition?
[Note: We do not automatically deny housing based on this information. It is used only to ensure appropriate placement and create a safe, supportive environment for all residents.]
Section 6: Final Questions
Why are you interested in this opportunity? *
Is there anything else you’d like us to know?
ImmediatelyWithin 2 WeeksNext 30 DaysNext 60 DaysOther
Should be Empty:

Jones Second Chance Housing (Men’s Independent Living Program)

Section 1: Personal Information

Section 2: Current Situation

Section 3: Referral Information

Section 4: Support & Income

Section 5: Housing Needs

Section 6: Final Questions