Independent Housing Intake Form
This intake form is for shared housing. The questions are designed to select the correct housing for your needs. Requirement: Income- Must be able to afford at least $700 per month. No Credit Check is needed. Once the form is completed, someone will contact you within 48 hours.
Client's Name:
*
First Name
Last Name
What city and state are you looking for housing?
Gender:
Please Select
Female
Male
Non-Binary
Transgender
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Race
Client Current Living Situation
What type of room does the client prefer?
*
Shared room
Private Room
When does the client need to be placed?
-
Month
-
Day
Year
Date
How much income does the client receive monthly? If none, please type NONE
*
Does the client suffer from mental illness?
*
Yes
No
If yes, enter mental diagnosis?
Does the client currently or in the past had any substance abuse issue?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
Is the client a convicted of a felony?
Yes
No
Is the client disabled?
*
Yes
No
If yes, please explain briefly:
Does the client need the following services:
Apply for SSI/SSDI
Apply for SNAP benefits
Apply for Veteran benefits
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Paycheck
Other
Representative or Caseworker Name / Email/ Number
Representative's Organization (ex. VA, HUD. etc)
Additional Notes
How did you hear about us?
Please upload any proof of income such as award letter from SSI/SSDI or pay stub
Browse Files
Drag and drop files here
Choose a file
Cancel
of
We offer a $50 referral fee. If someone refers you, please add their name and contact information (number or email address)
Submit
Should be Empty: