Housing Prescreening
Applying isn't a guarantee of acceptance into the program. We will contact you with in 24- 48hours to inform you of your application status. Thank you.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
E-mail
example@example.com
Phone Number
-
Area Code
Phone Number
What is your current living situation?
Medical Facility
Shelter
Incarcerated (Re-entry)
Homeless
Other
If other- please explain
What is your source of income
How much is your monthly income?
How often do you receive income?
Weekly
Bi-weekly
Monthly
When do you need housing?
-
Month
-
Day
Year
Are you willing to live in a shared housing environment?
Yes
No
Room request type
Private- (Depends on availability)
Shared
Have you been seen by a doctor or had a hospital visit in the last 90 days? if yes, explain what the visit was for and the result of the visit/hospital stay.
Are you disabled?
Yes
No
If yes, what is your disability?
Are you able to live safely on your own with no assistance? If assistance is needed please explain what type of assistance you need.
Are you currently working with a social worker or case manager?
Yes
No
If yes, name of person/organization and phone number
Do you have a health or mental diagnosis? if yes list the diagnosis and prescribed medication.
Do you take your medication as prescribed by your physician?
Yes
No
Sometime
Do you have a history of substance abuse?
Yes
No
If yes, what is the substance and the last time used?
Are you in treatment program or seeking treatment?
Yes
No
Have you ever been convicted of a felony? or a crime with in the last 5 years? selecting yes doesn't disqualify you from housing.
Yes
No
If you answered yes to the above, please briefly explain.
Are you on probation or parole?
Yes
No
Are you a registered sex offender?
Yes
No
Any additional Information
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