Client Pre-Screening Application
Your journey toward independence and stability begins here. This brief form helps us understand your current housing needs and determine the best placement and support for you. Please answer each question honestly — all information is kept confidential and used only to assist with housing eligibility. Once submitted, a member of the Anchor Haven Solutions team will contact you within 24–48 hours to discuss next steps.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date of Birth
Gender
Female
Male
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Move-In Date
-
Month
-
Day
Year
Date
Who will be occupying the room?
Myself
Myself and spouse/partner
Myself and child(ren)
Myself, spouse/partner, and child(ren)
Do you currently have stable income or housing assistance?
Yes
No
Are you currently employed?
Yes
No
Do you have any pets?
Yes
No
What type of housing are you interested in?
Shared Bedroom
Private Bedroom
Please select your preferred housing payment frequency:
Weekly
Biweekly
Monthly
Are you currently working with a case manager or social worker?
Yes
No
If yes, please list the Case Manager's Name and Agency:
Name and Agency
Our goal is to help clients live as independently as possible. Do you feel comfortable living in a setting that provides minimal daily assistance?
Yes
No
Our homes are alcohol-, and drug-free. Are you willing to follow these guidelines while residing in the program?
Yes
No
How Did You Hear About Us?
We love to know how people find our programs so we can recognize our community partners and continue reaching those who need stable housing. Your answer helps us show appreciation and improve our outreach efforts.
How did you hear about Anchor Haven Solutions?
Case Manager or Social Worker
Community Partner or Organization
Referral from Current/Previous Client
Online Search/Google
Flyer or Event
Social Media
Other
Consent and Acknowledgment
*
I certify that the information provided in this form is complete and accurate. I understand that this information will remain confidential and is used solely to determine eligibility for housing with Anchor Haven Solutions.
Submit
Should be Empty: