Trinity Residential Solutions Intake Form

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
Full Name*
Date of Birth *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email (optional)
example@example.com
What city are you currently located in?*
Referral Source

Case Manager/AgencyShelter/Transitional ProgramProbation/ParoleHospital/ClinicOutreach WorkerSelf-ReferralOther
Section 2 - Housing Details
Preferred Move-In Date*

MonthDayYear
Date
Gender:*

MaleFemaleNon-binaryPrefer not to say
Are you applying for:*

Shared Room (primary availability)Private Room (limited availability — higher rate)
Section 3 - Program Requirements
Can you live independently without daily assistance?*

YesNo
If no, explain:
Do you have any accessibility needs?*

YesNo
If yes, explain:
Section 4 - Current Situation
Current Living Situation*

HomelessShelterTransitional HousingCouch SurfingRehab/RecoveryRecently IncarceratedFleeing Domestic ViolenceOther
Section 5 - Income Information
Primary Income Source*

EmploymentSSI / SSDIVeterans BenefitsPrivate PayOtherNone
Monthly Income Amount *
Will you be able to pay the move-in amount upon arrival?*

YesNo
If no, explain:
Section 6 - Additional Information

(This does not disqualify you; it helps us better understand your needs)
Mental Health Conditions*

YesNo
Substance Use History*

YesNo
Background Concerns*

ProbationParolePrior ConvictionsRegistered Sex OffenderNone
FINAL STEP
Upload a photo of your ID (optional - if available)

Cancelof
Upload proof of income (optional - if available)

Cancelof
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*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Trinity Residential Solutions Intake Form

Section 1 - Personal Information

Section 2 - Housing Details

Section 3 - Program Requirements

Section 4 - Current Situation

Section 5 - Income Information

Section 6 - Additional Information

FINAL STEP