Room to Rest - Participation Program Intake Form

  • Room to Rest - Participation Program Intake Form

    Redefining shared community housing through Safety, Stability, Structure, and Support!

  • Basic Information

  • Date of Birth:*
     - -
  • Format: (000) 000-0000.

  • Income & Benefits

  • Do you have a source of income or financial support?*
  • Do you currently receive SNAP/EBT (Food Assistance)?*
  • What is the best way to contact you?*

  • Independent Living Ability

  • Are you comfortable managing your daily living needs in a shared community environment?*
  • Do you currently receive support services or assistance with daily living tasks?(cleaning, cooking, hygiene, transportation, appointments, etc.)?*
  • Do you independently manage your medications and medical needs?*
  • Would you like assistance connecting to healthcare or medication resources?*
  • Do you have difficulty accessing medications or healthcare services?*
  • If yes:*

  • Parent/ Expecting Parent Information

    Please complete this section if you are currently pregnant and/or have children living with you or who may be joining you in the program.
  • Are you currently pregnant ?
  • Do you currently have any children?
  • Do you currently have any children?
  • Are your children currently enrolled in school or daycare?
  • Do any of your children have special needs, disabilities, or medical conditions we should be aware of?
  • Are your children currently living with you?
  • Are you currently receiving any assistance or support services for yourself or your children?

  • Military Affiliation

  • Do you have any military affiliation?*

  • Housing Preferences & Needs

  • What type of room are you looking for?*
  • Desired move-in date:*
     - -
  • Do you have any mobility or accessibility needs we should consider for housing placement?*
  • Which housing accessibility preference best fits your needs?*

  • Safety & Placement Information

  • Have you experienced an eviction or housing-related issue in the past?*
  • Do you have any felony convictions or pending felony charges we should be aware of for placement purposes?*
  • Are you currently required to register as a sex offender?*
  • Are you currently on probation, parole, or supervised release?*

  • Lifestyle & House Rules

  • Are you willing to follow Room to Rest community guidelines and shared living expectations (quiet hours, cleanliness, approved guests, substance-free environment, and respect for shared spaces)?*
  • Do you currently smoke or vape?*
  • Do you currently have any pets or service animals?*

  • Acknowledgment

  • Final Notes

  • Why are you seeking housing at this time?.*
  • How Did You Hear About Room to Rest?*
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  • Should be Empty: