Pre Screening
Independent Living Housing Program
Name
*
First Name
Last Name
D.O.B
*
Age
*
Gender
*
Male
Female
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
SSI
SSDI
VA Benefits
Employment
Other
If other, explain here.
What is your estimated monthly income?
*
How long have you been homeless?
Do you receive EBT/SNAP Benefits?
*
Yes
No
Are you able to live independently WITHOUT daily assistance?
*
Yes
No
Are you currently taking any prescribed medications?
*
Yes
No
Have you been Diagnosed with any Mental Illness Disorders
*
Anxiety
Depression
Bipolar
Schizophrenic
Other
Are you a convicted felon?
*
Yes
No
Are you a registered Sex Offender
*
Yes
No
Are you on Probation or Parole?
*
Yes
No
Are you willing to follow House Rules?
*
Yes
No
Are you okay with living in a Shared Housing Program?
*
Yes
No
Who referred you to Building Bridges Independent Living Housing Program? Include name of Agency/Hospital
*
When are you needing to move in?
*
I certify that the information provided is accurate.
*
SUBMIT
SUBMIT
Should be Empty: