Housing Questionaire Form
Start your journey to independent living. Fill out this quick 1-step form and our coordinator will contact you within 24–48 hours.
Full name
*
Date of Birth
*
Phone Number
*
Email Address (If Available)
Current Address
Where were you referred from?
*
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
SSI
SSDI
Employment
VA Benefits
Other
If Other, Write Here
What is your estimated monthly income?
*
Do you receive Food Stamps / EBT (SNAP benefits)?
*
Yes
No
Do you have a working phone we can use to contact you?
*
Yes
No
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?
*
Yes
No
If Yes, Please Explain
Are you currently taking any prescribed medications?
*
Yes
No
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
*
Yes
No
If Yes, Please Explain
What type of room are you looking for?
*
Shared Room
Private Room
Private Room with Bathroom
No Preference
When do you need housing? (Move-in date)
*
Do you have any physical disabilities or mobility concerns?
*
Yes
No
If Yes, Please Explain
Have you ever been evicted from a previous residence?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets?
*
Yes
No
Why are you seeking housing at this time?
*
Is there anything else you'd like us to know?
Submit
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