Housing Waitlist Form
*Please complete all fields
Name
*
First Name
Last Name
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
👤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 for 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
What are their ages?
add ages of children
What City or Zipcode are you looking to reside in?
*
Type zipcodes or cities
Are you willing to live in a shared, drug‑ and alcohol‑free environment? If your answer is NO please stop here. As we are a shared housing program.
*
Yes
No
I understand this is a Shared Housing Program
*
Yes
No
Room Preference - Which option are you applying for?
*
Shared Room
Private Room
🧍🏾 Are you independent? Can you care for yourself and manage daily routines?
*
YES
NO
Do you have your own means of transportation?
*
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 drink alcohol?
*
YES
NO
🚬 Do you smoke?
*
YES
NO
🤝 Do you have a support team (family, caseworker, etc.)?
*
YES
NO
Do you have a Mental health Diagnosis?
*
YES
NO
💊 Are you currently taking any medications?
*
YES
NO
⚖️ Have you ever been convicted of a crime?
*
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?
*
YES
NO
Tell us about yourself.
*
Referral Agency
Preferred Move‑In Timeframe.
*
Immediately
1-2 Weeks
30 Days
Not Sure
What is your total verifiable monthly income?
*
Enter total monthly income
💵 How Do You Plan to Pay for Housing? (Required)
*
SSI/ SSDI
SELF PAY
FAMILY SUPPORT
CASE MANAGER
Ability to Pay Acknowledgment
*
I understand there are monthly housing fees and confirm that I can consistently meet this requirement without relying on uncertain or temporary income.
Financial Stability - After paying your monthly housing fee, will you have funds remaining for personal expenses (transportation, phone, hygiene, etc.)?
*
Yes
No
If we are unable to assist do you consent to ud sharing your application with other trusted advisors?
*
Yes
No
📎 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
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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