• Trinity Residential Solutions Intake Form

    Please complete this form to be considered for housing. All information provided will remain completely confidential.

  • Section 1 - Personal Information

  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Referral Source

  • Section 2 - Housing Details

  • Preferred Move-In Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Our homes are located throughout East Contra Costa County. Please select your preferred location:*
  • Trinity Residential Solutions currently provides shared housing only. Are you comfortable with shared accommodations?*
  • Important: If you select No, you will not be contacted regarding housing, as we do not currently offer private housing options.
  • If your preferred location is unavailable, would you be open to placement at another Trinity Residential Solutions home?*
  • Gender:*

  • Section 3 - Program Requirements

  • Can you live independently without daily assistance?*
  • Do you have any accessibility needs?*

  • Section 4 - Current Situation

  • Current Living Situation*

  • Section 5 - Income Information

  • Primary Income Source*
  • Will you be able to pay the move-in amount upon arrival?*

  • Section 6 - Additional Information

    (This does not disqualify you; it helps us better understand your needs)
  • Mental Health Conditions*
  • Substance Use History*
  • Background Concerns*

  • FINAL STEP

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  • Certification (Required):

    I certify that the information provided is true and accurate. I understand that submission of this form does not guarantee housing placement and that I may be placed on a waitlist until space becomes available.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: