Waiting list Intake Form
Thank you for inquiring about our waiting list here at Families Connexx Residential Services! We look forward to serving you as we work getting through application and locating the right fit home for you, please take the time to fill out this form, so that the proper specialist can get back to you to conduct your interview and intake. Thank you again for your patience and cooperation.
Applicant Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Photo ID
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Choose a file
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Upload Selfie Photo
*
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Gender
*
Male
Female
Non Binary
Other
Do you smoke?
*
Yes
No
Are you a Convicted Felon?
*
Yes
No
Are you on state or federal supervision? (Parole/Probation)
*
Yes
No
What is your current living situation?
*
Homeless
Re-Entry
Domestic Violence
Veteran
Respite
Hotel/Motel
Transitioning
Are you a woman/man with children?
*
Yes
No
Are you employed?
*
Yes
No
Do you have a vehicle?
*
Yes
No
Our independent residential homes require a source of income. Please check off all that apply to you. Please be prepared to provide proof of income.
*
Private Pay
Employment
SSi/SSDI
Medicaid/Medicare
VA Benefits
Other
Employment/Income Proof
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Choose a file
Employment Letter, Two Months Pay Stubs, etc.
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Our Program Requires an administrative fee and first month rent to enter program. Are you able to provide requirements to move in?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Majority of our homes are semi private. If you are interested in a private room, please note this below so that our intake specialist can go over private room packages and pricing. Private rooms are at limited availability.
*
Yes
No
Are there any Motility Limitations?
*
Yes
No
Our Program is customized and tailored to each individual. We offer many services as listed on our website. Please list and note all services required below to discuss with our intake team.
Notes
All of Our Individuals are subject to a background check. At Families Connexx Residential Services, everyone is treated like family. We believe in honesty, safety, integrity, quality of care and compassion to the individual we serve. Please disclosed, if anything, any crimes that may appear on background check.
Notes
How soon are you looking to transition into one of our homes? Please provide a date.
*
-
Month
-
Day
Year
Date
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
If we do not have availability for your need, we have over 200,000 resources available nationwide. Please provide the following information and we will connect you with our outsource department.
What City and State are you looking for housing in?
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Employment
Company Name
Starting Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor Name
Title
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Salary $
Monthly
Reference
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Notes
What Payment Method do you plan to use?
Cash
Zelle
Venmo App
Square Cash App
Paypal
Google Pay
Other
Submit
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