Housing Interest & Pre-Screen

Housing Interest & Pre-Screen
Welcome to Day Rise Living

This Housing Interest & Pre-Screen is for individuals interested in shared or independent transitional housing with Day Rise Living.

The information collected through this form is used to understand your current situation, assess potential fit, and review housing availability. Submission of this form does not guarantee housing or placement.

If you are identified as a potential fit, you may be contacted to complete a separate intake packet and participate in next steps, which may include additional screening and a meet-and-greet.

Final housing decisions are made after review, screening, and a meet-and-greet, based on program fit and availability.

Please answer all questions honestly and completely. All information will be kept confidential and used only for housing evaluation purposes.
Section 1: Participant Information
Full Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
May we contact you by phone or text regarding housing availability and updates?*

Yes, you may call meYes, you may text meNo, I prefer email onlyOther
Email Address
example@example.com
Emergency Contact (Name / Relationship / Phone)
Your consent allows Day Rise Living to send limited updates related to housing and support services. You may opt out anytime.
Section 2: Living Situation & Room Preference
What is your current living situation?*

HomelessStaying with family or friendsTransitional programOther (please explain)
What type of room are you seeking?*

Shared Room (semi-private)Private Room
Desired move-in date:

MonthDayYear
Date
Section 3: Health & Wellness
All information is confidential and used only to determine appropriate housing support.
Do you have any mental health or behavioral health conditions that may impact your ability to live independently in a shared housing environment?*

YesNoPrefer not to sayIf yes, please briefly describe how this affects your daily functioning or housing needs (optional):
Are you under the care of a doctor, psychiatrist, or therapist?*

YesNo
Do you require help with Activities of Daily Living (ADLs) such as bathing, dressing, meal prep, or transportation?*

IndependentNeed Some AssistanceNeed Full Assistance
Do you have any medical conditions or allergies that may impact shared living or housing placement? (optional)
Do you use any medical or sleep-related devices at night (e.g., CPAP, oxygen, etc.) that we should be aware of for placement purposes?*

YesNoIf yes, please explain (optional):
Section 4: Income & Benefits
Do you have a verifiable source of income?*

YesNo
If yes, please indicate:*

EmploymentSSISSDIVA BenefitsOther (specify):
Section 5: Legal Background
A criminal background does not disqualify you. This information helps us meet compliance and safety guidelines.
Have you ever been convicted of a crime?*

YesNoIf yes, please explain (optional):
Are you currently required to register as a sex offender under state or federal law?*

YesNo
Section 6: Substance Use
Are you currently using or recovering from substance use (alcohol or drugs)?*

NoIn RecoveryCurrently UsingPrefer not to sayIf in recovery, how long have you been sober?
Section 7: Lifestyle & Room Compatibility
Do you smoke cigarettes or vape?*

YesNoOccasionally
Are you comfortable sharing a room with another participant (if applicable)?*

YesNoPrefer Private Room
Section 8: Support System / Circle of Support
Do you currently have a support system (caregiver, case manager, family, or friend)?*

YesNoIf yes, please list names, relationship and contact information (optional):
Are you receiving services from any agency or program (e.g., Regional Center, VA, Behavioral Health, Reentry Program)?*

YesNoIf yes, please specify:
Section 9: Additional Information
Gender Identity / Pronouns: (optional)*
Veteran Status:*

YesNoActive ServiceRetired
Transportation Access:*

Public TransitPersonal VehicleNeeds Assistance
Preferred City or Area:*
Anything else you'd like us to know to help determine the best placement for you:*
Section 11: Applicant Acknowledgment
I acknowledge that the information provided in this Housing Interest & Pre-Screen is true and complete to the best of my knowledge. I understand that submission of this form is for screening purposes only and does not guarantee housing or placement with Day Rise Living.

I understand that Day Rise Living does not accept Section 8 vouchers, requires a background check as part of the review process, and determines eligibility based on program fit, availability, and additional screening steps.
I have read and understand the above acknowledgment.*
Privacy & Confidentiality Notice

Day Rise Living respects and protects your privacy. All personal and sensitive information shared in this form is strictly confidential and used only to determine appropriate housing placement and support services.

Information is stored securely and will not be shared with outside parties without your written consent, except as required by law or authorized agencies directly involved in your care or placement.
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Housing Interest & Pre-Screen

Section 1: Participant Information

Section 2: Living Situation & Room Preference

Section 3: Health & Wellness

Section 4: Income & Benefits

Section 5: Legal Background

Section 6: Substance Use

Section 7: Lifestyle & Room Compatibility

Section 8: Support System / Circle of Support

Section 9: Additional Information

Section 11: Applicant Acknowledgment