New Bloom- Prescreen/ Waitlist Form

Full Name

First NameLast Name

Pronouns

Date of Birth

ex: 00/00/0000

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Preferred Move-In Date:

MonthDayYear

Location Preference:

Room Preference:

Guaranteed Income Source:

Can you verify this income?

Total Monthly Income amount?

$

Monthly Housing budget? (How much are you trying to spend on your room rent per month?)

$

When would funds be available for move in?

What is your benefit date? (What day do you receive your money) or What day of the week do you get paid from your job?

Support Needed:

If you have been prescribed medications, are you currently taking them as directed?

Are you currently drug and alcohol free?

If yes: Approximately how long?

Do you smoke or vape?

Can you independently manage your personal hygiene and daily living needs?

Do you require assistance with any daily living activities or personal care needs?

If yes to the question above, please explain.

Do you receive SNAP Benefits?(Food Stamps)

Other

Do you have medical insurance?

What kind of insurance?

Please select any that apply to your current situation:

Where are you staying right now?:

Do you have any history of sex-offender registration or violent felony charges? This information is used solely to determine housing eligibility and does not automatically disqualify you.

Are you on probation/ parole or have any active/ pending charges?

Do you have a case manger, social worker, probation officer or other support person ?

What is the case manager, social worker, probation officer, or other support persons’ name and phone number?

Please tell us a little about yourself, any medical, mobility, personal needs or support you may require, and why you’re interested in joining the New Bloom community:

Referral Source/ How did you hear about us?

ex. Agency, Facebook, Instagram, Google, etc.

Thank You for Applying!

Your prescreen application has been received. Our admissions team will review your information and contact you if a room becomes available or if we need additional information.

Please monitor your phone and email. If your contact information changes, let us know so we can keep your application current.

Join the New Bloom Community: Prescreen & Waitlist Application