Housing Prescreening Form

Housing Prescreening Form
SECTION 1 — Applicant Information
Full Name *
Date of Birth*

MonthDayYear
What is your gender?*

MaleFemaleNon-binaryPrefer not to sayOther
Are you pregnant? (This information helps us provide appropriate accommodations and support.)*

YesNoMaybeNot sureNot Applicable
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Emergency Contact Name *
Emergency Contact Phone *
Please enter a valid phone number.
Relationship to Emergency Contact*
SECTION 2 — Housing Need & Reason for Seeking Housing
Housing type requested*

Shared supportive housingTransitional housingRoom rental
When do you need housing?*

ImmediatelyWithin 30 days1–3 months
Reason for seeking housing*
(prompt examples: homelessness, instability, safety concerns, recovery support, affordability, relocating)
Current housing status*

Stably housedUnstably housedHomelessAt risk of losing housing
Length of housing instability*

Less than 30 days1–6 months6–12 months1 year or more
SECTION 3 — Supportive Housing Fit
Comfort with shared living?*

YesNo
Willing to participate in supportive services such as, counseling, case management, job training, life skills development, etc.?*

YesNoMaybe
Please let us know if you are involved in any of the following:*

Alcohol ConsumptionSmokingSubstance UseGamblingNone
If you answered yes to the question above, please explain. *
Do you have any medical conditions/concerns?*

YesNo
If yes, please explain. (List medications if any.)*
Have you ever received a professional diagnosis for any mental health conditions?*

YesNoNot Sure
If yes, please explain. (List medications if any.)*
SECTION 4 — ADLs (Activities of Daily Living)

Please mark the level of support needed for the following.*

Rows	Independent	Some assistance needed	Full assistance needed
Bathing
Dressing
Cooking
Eating
Toileting
Medication management
Housekeeping
Transportation
Money management

Currently receive ADL assistance?*

YesNo
If yes, who provides assistance?*
SECTION 5 — Support Services & Needs
Currently work with any of the following? (Multiple Choice)*

Case managerSocial workerTherapist/CounselorProbation/ParoleNone
Accessibility or accommodation needs?*
Currently in treatment or recovery support?*

YesNoPrefer not to answer
SECTION 6 — Income & Community Fee
Monthly income range*

$0–$999$1,000–$1,999$2,000–$2,999$3,000+
Income source (Multiple Choice)*

EmploymentSSI/SSDIDisability benefitsFamily assistanceOther
Ability to pay required community fee*

YesNoNeed assistance/payment plan
SECTION 7 — Background & Eligibility Screening

We value honesty and confidentiality. Please be open about your background, as this information is kept private and will help us provide the best possible support. Please note that certain circumstances will be considered on a case-by-case basis.
Eviction history?*

YesNo
Short paragraph explanation if yes*
Criminal history?*

YesNo
Short paragraph explanation if yes*
Are you currently on probation?*

YesNo
Short paragraph explanation if yes*
Do you have an open DCF case?*

YesNo
Short paragraph explanation if yes*
Please note that Rise and Renew Living LLC is unable to accept individuals with violent offenses or sexual offenses. This policy is in place to ensure the safety and well-being of all residents. We appreciate your understanding and honesty.
Confirmation Statement*

I confirm that I do NOT have violent or sexual offense convictionsI do not meet this requirement (I understand I am not eligible)
Violence-free, drug-free environment agreement*

YesNo
SECTION 8 — Community Expectations (Yes/No)
Mark if you agree to the following*

I will respect roommates and shared spacesI will follow house rulesI understand supportive housing is not custodial careI understand this form does not guarantee placementI certify my answers are truthful
SECTION 9 — Final Questions & Signature
How did you hear about us?*

Social mediaReferralCommunity agencyOnline searchOther
Anything else we should know?*
Electronic Signature*
Date Signed*

MonthDayYear
Should be Empty:

Housing Prescreening Form

SECTION 1 — Applicant Information

SECTION 2 — Housing Need & Reason for Seeking Housing

SECTION 3 — Supportive Housing Fit

SECTION 4 — ADLs (Activities of Daily Living)

SECTION 5 — Support Services & Needs

SECTION 6 — Income & Community Fee

SECTION 7 — Background & Eligibility Screening

Please note that Rise and Renew Living LLC is unable to accept individuals with violent offenses or sexual offenses. This policy is in place to ensure the safety and well-being of all residents. We appreciate your understanding and honesty.

SECTION 8 — Community Expectations (Yes/No)

SECTION 9 — Final Questions & Signature