Jones Second Chance Housing: Interest Form

Jones Second Chance Housing: Interest Form
Section 1: Personal Information
Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Phone Number (Primary)*
Please enter a valid phone number.
Email Address*
example@example.com
Emergency Contact - Full Name*
Emergency Contact - Phone Number*
Please enter a valid phone number.
Section 2: Current Situation
Select a status that is applicable to you right now.*

Currently IncarceratedRecently ReleasedOther
Date of Release (if applicable)

MonthDayYear
Date
Do you currently have stable housing?

YesNo
If not, where are you currently staying?

ShelterHomeCouch-to-CouchStreet/HomelessTransitional HousingOther
Section 3: Referral Information
Were you referred by an organization or individual?*

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
Do you have a case manager, parole officer, or reentry program you’re working with?*

YesNo
If yes, please provide their name and contact information:
Do you receive any form of income or public assistance (e.g., SSI, SSDI, SNAP)?*

YesNo
If yes, please list the type(s) of income or assistance you receive:
Are you currently employed or seeking employment?*

EmployedSeeking WorkNot currently seeking
Section 5: Housing Needs
Are you comfortable sharing a room with another resident?*

YesNoMaybe
If maybe, please explain:
Do you have any special needs or accommodations we should be aware of?*

YesNo
If yes, please describe:
Do you have a history of violent or sexual offenses?*

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?
Preferred move-in timeframe:

ImmediatelyWithin 2 WeeksNext 30 DaysNext 60 DaysOther
Should be Empty:

Jones Second Chance Housing: Interest Form

Section 1: Personal Information

Section 2: Current Situation

Section 3: Referral Information

Section 4: Support & Income

Section 5: Housing Needs

Section 6: Final Questions