Legacy's Second Chance Pre-Screening Form

Please provide your information and answer the following screening questions.

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Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (if available)
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Where were you referred from?
YesNo
What is your main source of income?*
What is your estimated monthly income? (We may ask for confirmation - proof can be shown in person or sent electronically)
YesNo
YesNo
YesNo
YesNo
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc)? If yes, please explain
YesNo
YesNo
SharedPrivatePrivate room with a bathroomNo preference
When do you need housing?*

MonthDayYear
Date
Do you have any physical disabilities or mobility concerns? If yes, please explain
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Why are you seeking housing at this time?
Is there anything else you'd like us to know?
Should be Empty:

Please provide your information and answer the following screening questions.