This form collects basic information to determine eligibility and ensure appropriate housing placement. Completion of this form does not guarantee acceptance.
Applicant Information
Full Legal Name:
Preferred Name:
Date of Birth: mm/dd/yyyy
-
Month
-
Day
Year
Date
Gender
Social Security Number
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
City / State / ZIP:
2. Emergency Contact
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Alternate Phone:
Format: (000) 000-0000.
3. Referral Information
Referred By (self / agency / individual):
Agency or Organization Name (if applicable):
Contact Person:
Phone / Email:
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4. Housing Needs
Requested Move-In Date:
-
Month
-
Day
Year
Date
Length of Stay (temporary / long-term / unsure):
Type of Bed Requested:
Shared Room
Special Housing Requests (optional):
5. Income & Payment Information
Primary Source of Income:
Employment
SSI / SSDI
Pension
Other
Monthly Income (approximate):
Payment Method:
Self-pay
Representative Payee
Agency Pay
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6. Medical & Functional Information (Basic)
For housing placement purposes only
Do you require daily medical care?
Yes
No
Are you able to perform daily activities independently?
Yes
No
Mobility Aids Used (if any):
Allergies (if any):
7. Behavioral & Safety Information
History of violent behavior?
Yes
No
Registered sex offender?
Yes
No
Active substance use issues?
Yes
No
Legal restrictions or probation/parole?
Yes
No
If yes to any above, please explain briefly:
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9. Applicant Statement
I certify that the information provided is true and complete to the best of my knowledge. I understand that false information may result in denial or termination of housing.
Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Please upload a valid form of identification here
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