Housing Waitlist Form
*Please complete all fields
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
👤Gender Identity.
*
Male
Female
Non-binary
Prefer to self-describe: ___________
Which best describes you?
*
Veteran
Elderly
Adult needing affordable housing during a rough time
Other
If other, please explain
🐾 Do you have a service animal or emotional support animal? Please note: Documentation may be required accommodation.
*
Yes
No
Do you have children that will need to live with you? .
*
Yes
No
If Yes, how many?
1
2
3
more than 3
Are you willing to live in a shared, drug‑ and alcohol‑free environment?
*
Yes
No
🧍🏾 Are you independent? Can you care for yourself and manage daily routines?
*
YES
NO
We do not provide medical care or assistance with daily living activities. All clients must be independent.
*
I understand that no medical assistance is provided.
🚬 Do you smoke? (Required)
*
YES
NO
🍷 Do you drink alcohol? (Required)
*
YES
NO
🤝 Do you have a support team (family, caseworker, etc.)? (Required)
*
YES
NO
Do you have a Mental health Diagnosis? (Required)
*
YES
NO
💊 Are you currently taking any medications? (Required)
*
YES
NO
⚖️ Have you ever been convicted of a crime? (Required)
*
YES
NO
📋 Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*
*
YES
NO
📋 Are you currently on probation or parole? (Required)
*
YES
NO
Tell us about yourself.
*
Referral Agency
Preferred Move‑In Timeframe.
*
Immediately
1-2 Weeks
30 Days
Not Sure
💰 Monthly Income (Required)
*
💵 How Do You Plan to Pay for Housing? (Required)
*
SSI/ SSDI
SELF PAY
FAMILY SUPPORT
CASE MANAGER
📎 Upload Income Verification
*
Browse Files
Drag and drop files here
Choose a file
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of
TODAY'S DATE
*
-
Month
-
Day
Year
Date
I confirm that the above information is accurate, and I understand someone will contact me within 48 hours.” – Required
*
Please Select
YES
Final Note: Submitting this form does not guarantee housing. All applications are reviewed, and eligible individuals will be contacted when a space becomes available.
*
I Understand
Submit
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