Pre Screener Form
Name
First Name
Last Name
Last Address or Current
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Gender
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Do you currently have a stable source of income?
*
Yes
No
I will soon
If yes, What type?
*
Monthly income amount?
*
Are you able to pay a monthly program fee starting at $700/month, plus a small program entry fee?
*
Yes
No
Not quite $700 but almost
Are you open to sharing a room with another adult?
*
Yes
No
Are you willing to follow strict house rules ( No guests, no drugs, clean space, etc.)
*
Yes
No
Do you receive from support from a caseworker, family member, or program?
*
Yes
No
Do you have any allergies, medical conditions, mental illness, or anything we should be aware of?
*
Yes
No
If yes, explain
*
Do you currently take any medications?
*
Yes
No
Do you require any mobility or health- related accommodations?
*
Yes
No
Have you ever been incarcerated? ( This does not automatically disqualify you.)
*
Yes
No
If yes, when and what was your charge?
What’s are you hoping to gain from your next housing placement?
Are you planning to move in with a spouse?
Do you have children that live with you?
Yes
No
If yes, how many? And how old are they?
What your preferred move in date or timeline?
*
Anything else you would like us to know?
Submit
Should be Empty: