Housing Pre Screening Application
Basic Information:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
*
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral & Housing:
Are you currently on supervision?
*
Please Select
Probation
Parole
None
Other
Who referred you? Caseworker/Agency Name
*
Are you willing to share a room?
*
Yes
No
Income & Benefits
What is your monthly income amount?
*
Income Source (Check all that apply)
*
SSI
SSDI
VA Benefits
Other
If "Other" please explain:
Do you have a valid ID, SSN, and Proof of income?
*
Valid ID
SSN
Proof of Income
Background & Legal
Have you ever been convicted of a violent or sexual offense?
*
Yes
No
If yes, please explain:
Are you currently facing any pending legal charges?
*
Yes
No
If yes, please explain:
Mental Health & Wellness:
Have you ever been diagnosed with a mental health condition?
*
Yes
No
If yes, do you have a treatment or medication plan in place?
*
Yes
No
Are you currently receiving counseling or support services?
*
Yes
No
Substance Use History
Have you struggled with substance use in the past?
*
Yes
No
Are you currently sober?
*
Yes
No
If yes, how long?
Logistics:
When are you looking to move in ?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about New Pathway Living?
Submit
Should be Empty: