Independent housing intake assessment

  • Please read the following carefully before completing this form: 

    This application is designed to collect information regarding your housing and move-in needs so we can help find the best placement for you.

    There are no application fees required to complete this form, and you are not committed to any payment unless you are approved and accept placement into the housing program.

    Please answer all questions honestly and thoroughly so we can better match you with a housing option that fits your needs and situation.

  • Date of Birth*
     - -
  • Race
  • Do we have permission to text/leave a message on the number provided?*
  • Currently living situation?*
  • Are you comfortable with sharing a room ?*
  • Do you require a handicap accessible environment?*
  • Are you disabled?*
  • Are you able to go up and down a flight of stairs*
  • Are you able to live independently without any assistance?*
  • Are you currently employed?*
  • Do you have a mental health illness?*
  • How will you pay?*
  • Desire move in date?*
     - -
  • Do you have funds available now?*
  • Bridge card/food stamp card?*
  • Are you a veteran?*
  • Do you have a misdemeanor or felony?*
  • Are you a registered sex offender?*
  • Do you have Health insurance?*
  • Do you use a cane or a walker?*
  • Select the assistance needed *
  • (function () { //hide wrapper var m_responsive = $$('.mobile_responsive')[0]; m_responsive.up('li').setStyle({ display: 'none' }); })();
  • Should be Empty: