HOUSING INQUIRY FORM
PHC MINISTRIES
Referral Source (if applicable)
Participant Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Female
Male
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Mobility & or accessibility needs? Yes or no (Explain if yes)
*
Current Living Situation
*
Homeless Shelter
Motel/Hotel
Transitional Program
Family/Friends
Car/Street
Other
Income/Employment
Employment Status
*
Employed
Disability
Unemployed
Seeking Employment
Other
Source of Income (check all that apply)
*
Social Security
Employment
TANF
Disability
None
Other
Monthly Income Amount $:
*
Move in Date Requested
*
Diagnosis and Medication List
Support & History
Have you ever lived in SHARED HOUSING before?
*
Yes
No
Check which applies to you : I have a
Social Worker
Case Manager
Probation Officer
Support Worker
Family Assistance
Other
If YES, list name + contact number
*
Background concerns we should be aware of (judgement free zone, for safety only)
*
Incarceration
Mental Health
Domestic Violence Survivor
Medical Issues
Sexual Offense
Arson
Other
Emergency Contact
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Agreement & Signature
Copy of Identification
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Added Info/Questions
I acknowledge that Respite Connect offers shared housing with established house rules, expectations, and program guidelines designed to ensure a safe, respectful, and clean-living environment for all residents. I agree to comply with all rules and to complete the intake process truthfully and in good faith.
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