Please review the eligibility criteria and program requirements above prior to completing the application.
Applications submitted by individuals who do not meet the eligibility criteria will not be considered.
Back
Next
Milestone Place Housing Application
Milestone maintains a Clean and Sober environment
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Alias:
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Place of Birth:
Are you currently enrolled in another program?
*
YES
NO
If yes, explain.
*
Gender
*
Man
Woman
Non-Binary
Other
Ethnicity
*
Hispanic or Latino
Non Hispanic or Latino
US Citizen?
*
YES
NO
If no, what is your Immigration Status?
*
Are you currently empolyed?
*
YES
NO
Case Manager Contact
Case Managers will be contacted as part of the application process.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Agency
*
Email
*
example@example.com
Homelessness
Must meet the definition of chronic homelessness
Are you currently homeless?
*
YES
NO
How did you become homeless?
*
Date you became homeless
*
/
Month
/
Day
Year
Date
Reason for leaving prior housing?
*
Name of Shelter/Institution you've stayed?
*
Have you ever been evicted?
*
YES
NO
If yes, Date of eviction?
*
/
Month
/
Day
Year
Date
Mental Health History
This does not make you ineligible for housing assistance.
Have you been hospitalized for an emotional or mental condition?
*
YES
NO
If yes, explain:
*
Have you received treatment and/or medication for emotional/mental condition?
*
YES
NO
If yes, explain:
*
Substance Abuse History
This does not make you ineligible for housing assistance.
Do you have a history of substance use?
*
YES
NO
If yes, what is your substance of choice and how often did you use?
*
Ever been treated for any addiction?
*
YES
NO
If yes, explain:
*
AA/NA/GA attendance?
*
YES
NO
If yes, where?
*
Do you have a sponsor?
*
YES
NO
Estimated last date of substance use?
*
Legal History
Milestone does not accept Class-A Sex offenders.
Have you been arrested before?
*
YES
NO
Is there currently a warrant out for your arrest?
*
YES
NO
Have you ever been convicted of a crime?
*
YES
NO
Have you ever served jail/prison time?
*
YES
NO
If yes to any questions above, please explain and list previous arrest record.
*
Are you on probation or parole?
*
YES
NO
If yes, give probation or parole officers name, phone number and the date it ends.
*
References
References will be contacted as part of the application process.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship:
*
Completion of this application does not guarantee housing or supportive services.
Signature
*
Submit
Submit
Should be Empty: