Housing Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Who do you need housing for?
*
Self
You + Spouse
You + Kids
You + Spouse + Kids (family housing)
You + Other dependents
Other
Have you been incarcerated in the last 24 months?
*
Yes
No
Are you a registered offender?
*
Yes
No
Are you currently using any substances?
*
Do you have kids
*
Yes
No
Do you have custody
*
Yes
No
Please list Sex and Age Ex: Male 6 years old
*
Do you need wheelchair access or other accommodations ?
*
Select what you are receiving from the list below. Please select all that apply.
*
Calworks/GAIN
GR (Cash Aid)
Unemployment
Social Security (SSI)
Employed-Part-Time
Employed- Full-Time
Self Employed / Gig Work
Cash Income - Paid under the table
1099 - (Amazon, Uber, DoorDash, etc.)
Child Support / Spousal Support
Veteran Benefits
Pension / Retirement
Financial Support from Family / Friends
Not working but willing to work
No income
Other (Please specify)
Other, please specify
If you're working, where do you work?
*
Are you currently in school?
*
Yes
No
Tell us your story. Why are you currently in need of housing? What is preventing you from getting on your feet?
*
Submit
Should be Empty: