Under 62 - Shared Housing Referral

Under 62 - Shared Housing Referral

We can refer you to a shared housing home that accepts people under 62
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number*

Area CodePhone Number
When are you looking to move in? (Funds are due at move in) *

MonthDayYear
Date
What is your total monthly income? *
SSDISSIVAPensionDisabilityEmploymentWorkFamily Support
CentralWest HoustonKatySouth HoustonEast HoustonOtherNorth HoustonCypress/Tomball
YesNo
YesNo
Shared Room (starts at $750+ per month depending on location)Private Room (starts at $1500+ per month depending on location)
YesNoJust clicking
Do you have a subsidy from an agency? If so, please provide details.
VACommunity OutreachReentryCase WorkerSocial MediaClientHospital
YesNo
Just myselfMore than just myself
YesNo
Is there anything else you'd like to share?
NOTE: Most shared housing properties DO NOT allow smoking, drinking or overnight guests.

I UNDERSTAND THIS IS FOR REFERRAL.
Should be Empty: