United Steps Housing Program Intake Form
Please complete this form so we can assess eligibility and determine the most appropriate housing placement. All information provided is confidential and used solely for placement purposes.
Section 1: Applicant Information
Full Legal Name
*
First Name
Last Name
Preferred Name (if Applicable)
Gender
*
Please Select
Male
Female
I do not want to answer this question
Age
*
Date Of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
Homeless
Shelter
Transitional Housing
Friends/Family
Renting
Other
Referral source:
Agency
Case Manager
Hospital
Outreach Worker
Family/Friend
Self-Referral
Other
Section 2: Income & Benefits
United Steps Housing Program requires each member to have a source of income. Please check all that apply to you. Must show proof of income.
*
Employed
SSI/SSDI
Veteran Benefits
Private/Sponsor Pay
Other
Employment Status
*
Employed Full-Time
Employed Part-Time
Unemployed
Student
Other
Employer Name (If Applicable)
Total Monthly Income:
*
Do you receive SNAP / EBT (Food Stamps)?
Yes
No
Section 3: Independent Living Capacity
Are You able to Live Independently without daily assistance?
*
Yes
No
Do you currently receive assistance with daily activities (cleaning, cooking, hygiene, transportation, etc.)?
*
Yes
No
Do you experience difficulty accessing medications (cost, insurance, transportation, etc.)?
*
Yes
No
Do you require reminders for medications or appointments?
*
Yes
No
Are you currently receiving mental health services?
*
Yes
No
Current Medical Conditions (Optional)
Section 4: Housing Preferences & Accessibility Needs
Why are you seeking housing at this time?
*
Previous Housing Program (If any)
Room Preference
*
Private
Shared
If a private room is unavailable, are you open to a shared room?
*
Yes
No
Preferred Move-In Date:
Do you have any physical disabilities or mobility limitations?
*
Yes
No
Do you require a ground-floor or downstairs room?
*
Yes
No
Do you have reliable transportation?
*
Yes
No
Section 5: Background & Legal History
Have you ever been evicted?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you currently registered as a sex offender?
*
Yes
No
Do you have any pending legal matters or court cases?
*
Yes
No
Section 6: Lifestyle & House Expectations
Are you willing to comply with house rules (no drugs, no unapproved guests, cleanliness standards, curfew/quiet hours, respect for others)?
*
Yes
No
Do you smoke or vape?
*
Yes
No
Do yo have any pets?
*
Yes
No
Do you have any difficulty sharing space with others?
*
Yes
No
How would you describe your cleanliness level?
*
Very Clean
Average
Needs Improvement
Support Needs (Check all that apply)
*
Housing
Food
Employment
Transportation
Life Skills
Budgeting
Education
Mental Health
Medical
Other
Please list any additional support needs or comments
Identification( ID or Driver's License)
*
Proof of Income
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Save
Join Waiting List
Should be Empty: