Form
Full Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Phone
Text
Email
Current Living Situation
Homeless
Shelter
Transitional Housing
Couch-surfing
What type of housing are you seeking
Shared Room
Single Room
Either/First Available
Are you currently employed?
Yes
No
In job training
Looking for employment
Do you have any income at this time?
Yes
No
If yes, please describe source and amount:___________
Are you currently working with any case managers, programs, or outreach workers?
Yes
No
If yes, name/agency: _______________
Do you need help obtaining vital documents (ID, Social Security card, birth certificate)?
Yes
No
Do you have any history of justice involvement (incarceration, probation, etc.)?
Yes
No
Do you have any medical, mental health, or mobility concerns you'd like us to be aware of?
Yes
No
If yes, please explain: _______________
Are you ready to move into housing if a space becomes available?
Yes - immediately
No – need more time
If no, estimated date ready: _______________
If No, estimated move-in date
-
Month
-
Day
Year
Date
Are you willing to participate in supportive services (life skills, employment support, etc.) while in housing?
Yes
No
Unsure
I understand that being placed on the waitlist does not guarantee housing and that I will be contacted if a shared or single room becomes available.
I acknowledge and agree.
Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: