Housing Interest & Pre-Screen

1
Full Name* This field is required.
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Phone Number* This field is required.
4
May we contact you by phone or text regarding housing availability and updates?* This field is required.
Yes, you may call me
Yes, you may text me
No, I prefer email only
Other
5
Email Address
example@example.com
6
Emergency Contact (Name / Relationship / Phone)
7
Your consent allows Day Rise Living to send limited updates related to housing and support services. You may opt out anytime.
8
What is your current living situation?* This field is required.
Homeless
Staying with family or friends
Transitional program
Other
9
What type of room are you seeking?* This field is required.
Shared Room (semi-private)
Private Room
10
Desired move-in date:
Date
Month
Day
Year
11
All information is confidential and used only to determine appropriate housing support.
12
Do you have any mental health or behavioral health conditions that may impact your ability to live independently in a shared housing environment?* This field is required.
Yes
No
Prefer not to say
Other
13
Are you under the care of a doctor, psychiatrist, or therapist?* This field is required.
Yes
No
14
Do you require help with Activities of Daily Living (ADLs) such as bathing, dressing, meal prep, or transportation?
Independent
Need Some Assistance
Need Full Assistance
15
Do you have any medical conditions or allergies that may impact shared living or housing placement? (optional)
16
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?
Yes
No
Other
17
Do you have a verifiable source of income?
Yes
No
18
If yes, please indicate:
Employment
SSI
SSDI
VA Benefits
Other
19
A criminal background does not disqualify you. This information helps us meet compliance and safety guidelines.
20
Have you ever been convicted of a crime?
Yes
No
Other
21
Are you currently required to register as a sex offender under state or federal law?
Yes
No
22
Are you currently using or recovering from substance use (alcohol or drugs)?
No
In Recovery
Currently Using
Prefer not to say
Other
23
Do you smoke cigarettes or vape?
Yes
No
Occasionally
24
Are you comfortable sharing a room with another participant (if applicable)?
Yes
No
Prefer Private Room
25
Do you currently have a support system (caregiver, case manager, family, or friend)?
Yes
No
Other
26
Are you receiving services from any agency or program (e.g., Regional Center, VA, Behavioral Health, Reentry Program)?
Yes
No
Other
27
Gender Identity / Pronouns: (optional)
28
Veteran Status:
Yes
No
Active Service
Retired
29
Transportation Access:
Public Transit
Personal Vehicle
Needs Assistance
30
Preferred City or Area:
31
Anything else you'd like us to know to help determine the best placement for you:
32
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.
33
I have read and understand the above acknowledgment.
34
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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