Prescreening Renal Questionnaire (Room For Rent)

Please read the following carefully before completing this form:

This is not a rental application. This form collects basic information about you and your needs. There's no fees for this form. The purpose of this form is to determine whether you will be a good fit for the program or not. So please fill out the form truthfully. This will save time and we can tell you upfront whether you will are a good fit or not. We will need you to provide proof of income, should you be approved.
First and Last Name
Gender
Date of Birth

MonthDayYear
Date
Phone Number
E-mail
example@example.com
Occupation
What type of room do you need?
Your Monthly Income?
Reason for Moving
Move-In Date

MonthDayYear
Date
Do you have a substance use/abuse history?
Do you havea medical or mental diagnosis?
Do you have funds available for the administrative fee & 1st month rent?
Have you ever been convicted of a misdemeanor or felony?
Do you smoke?
Are you currently employed?
Are you a registered sex offender?
Are you currently homeless or facing homelessness?
Do you have a case manager/social worker/PO Officer/ Caretaker? If so, list the name and contact information.
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Should be Empty: