Housing Intake Application
Join our waitlist
Client's Name Client's Email
First & Last Name
example@example.com
Phone Number
*
Please enter a valid phone number.
Client's Gender*
Male
Female
Do we have permission to text/leave a message on the number provided?
*
Yes
No
Race
*
Caucasian
lslander
African American
American lndian / Native Aerican
Hispanic
Asian
Date Of Birth
-
Month
-
Day
Year
Date
Client's Current Living Situation*
Living With a Friend
Living on the stree
Living in a Car
Living in a Shelter
Incarcerated
Hospital/Facility
Shard Housing/Group Home
Other
When does Client need to be placed? *
-
Month
-
Day
Year
Date
How will the client pay ?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much Income do you receive monthly? If none please type NONE*
Confirm Income*
Browse Files
Drag and drop files here
Choose a file
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List any Medications you are currently taking.
Does the client suffer from mental illness?
*
Yes
No
If answered yes, list mental diagnosis . If none, type NONE
*
Are you disabled ?
Yes
No
List Disability(s) If none , Type NONE*
Does client require a Handicap Accessible Living environment*
Yes
No
Is the Client an ex-offender*
Yes
No
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Have you been convicted as a Sex Offender? (Your answer to this question does not disqualify you from our program & Services)*
Yes
No
Are you currently on Probation or Parole ?
*
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
Yes
No
Will the Client have children living with them (Please List ages)
Do You Have a (Case Manager) ?
Yes
No
If answered yes, list Contact Information.
Phone Number or Email
Do we have permission to contact case manager?
*
Yes
No
Select all of the services you are requesting.
*
Transportation Assistance
Job Placement
Apply for SNAP benefits
Apply for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone Donation
Cellphone/Tablet Assistance
Food Bank Assistance
Life Skills/Recovery Groups
How did you hear about us ?
Referral
Search Engine/Web
Social Media
Word of Mouth
Signature
*
Continue
Continue
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