Independent housing intake assessment

Please read the following carefully before completing this form:

This is not a rental application. This form collects basic information about you and your move-in needs. There's no fees for this form. The purpose of this form is to determine whether you will get approved or not. So please fill out the form truthfully. This will save time and application fees for you if we can tell you upfront whether you will get approved or not. A thorough background check will be performed once the actual application and fees are submitted.
First and Last Name*
Representative name
Gender*
Date of Birth*

MonthDayYear
Date
Phone Number*
E-mail*
example@example.com
Race

CaucasianAfrican AmericanHispanicAsianAmerican Indian/Native AmericanOther
Do we have permission to text/leave a message on the number provided?*

YesNo
Currently living situation?*

Living w/a friendLiving in a carLiving in a shelterLiving on the streetIncarceratedHospital/FacilityShared Housing/Group HomeOther
Are you comfortable with sharing a room ?*

YesNo
Do you require a handicap accessible environment?*

YesNo
Are you disabled?*

YesNo
Are you able to cook for yourself?
Are you able to go up and down a flight of stairs*

YesNo
Are you able to live independently without any assistance?*

YesNo
Are you currently employed?*

YesNo
Do you have a mental health illness?*

YesNo
How will you pay?*

SSI/SSDIRetirementVoucherOrganization FundingJobPrivate payOther
How much income do you receive monthly? *If none type. N/A*
Desire move in date?*

MonthDayYear
Date
Do you have a misdemeanor or felony?*

MisdemeanorFelony
Was it a violent offense or non-violent offence?

ViolentNon-Violent
Are you a registered sex offender?*

YesNo
By checking this box, you agreed to A one-time Community Fee of $200 that is required to secure your spot in the shared housing program. This fee is also used to help cover minor incidental damages that may occur during your stay.The $200 Community Fee is due at the time you accept a room/bed and sign the Agreement. It must be paid to secure your spot. This fee is non-refundable under all circumstances, including if you cancel before move-in or decide not to continue with your placement.*

I Agree
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