Client Pre-Screening Application
Your journey toward stability and independence begins here. This short form helps us understand your housing needs and determine the most appropriate placement and level of support. Please answer each question honestly. All information is kept confidential and used solely to assess housing eligibility. Once submitted, a member of the Haven of Second Chances team will follow up to discuss next steps.
Applicant Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Are you currently employed?
*
Yes
No
What is your current living situation?
*
Living alone
With family
With roommates
Group home or assisted living
Other
Are you currently receiving any support services?
*
Yes
No
If yes, please describe the support services you receive.
Do you have any mobility limitations?
*
No limitations
Use wheelchair
Use walker/cane
Other mobility device
Do you have any medical conditions or disabilities we should be aware of?
Are there any special accommodations or supports you require for independent living?
Emergency Contact Name
*
Do you currently have stable income or housing assistance?
*
Yes
No
Are you currently employed?
*
Yes
No
Do you have any pets?
*
Yes
No
What type of housing are you interested in?
*
Please Select
Shared Bedroom
Private Bedroom
What is your monthly housing budget?
*
$600-$800
$800-$1000
$1000+
Are you currently working with a case manager or social worker?
*
Yes
No
Do you feel comfortable living in a setting that provides minimal daily assistance?
*
Yes
No
Are you willing to follow alcohol- and drug-free guidelines while residing in the program?
*
Yes
No
How did you hear about Haven of Second Chances?
Case Manager or Social Worker
Community Partner or Organization
Referral from current/previous resident
Online Search/Google
Flyer of Event
Social Media
Other
Submitting this form does not guarantee housing placement.
Submit Application
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