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.
Email Address (if available)
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Where were you referred from?
Do you have a steady source of income?*

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)
Do you receive Food Stamps/EBT (SNAP benefits)?*

YesNo
Will you be able to provide an Award Letter confirming payment?*

YesNo
Do you have a working phone we can use to contact you?*

YesNo
Are you able to live independently without daily assistance?*

YesNo
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc)? If yes, please explain
Are you taking any prescribed medications?*

YesNo
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc)? If so, please explain*

YesNo
What type of room are you looking for?*

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
Have you ever been evicted from a previous residence?*

YesNo
Have you ever been convicted of a felony?*

YesNo
Are you a registered sex offender?*

YesNo
Are you willing to follow the house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?*

YesNo
Do you smoke?*

YesNo
Do you have any pets?*

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.