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?*

YesNo
Do you havea medical or mental diagnosis?*

YesNo
Do you have funds available for the administrative fee & 1st month rent?*

YesNo
Have you ever been convicted of a misdemeanor or felony?*

YesNo
Do you smoke?*

YesNo
Are you currently employed?*

YesNo
Are you a registered sex offender?*

YesNo
Are you currently homeless or facing homelessness?

YesNo
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: