Housing Prescreening Form

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

MonthDayYear
What is your gender?

Other
Are you pregnant? (This information helps us provide appropriate accommodations and support.)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
SECTION 2 — Housing Need & Reason for Seeking Housing
Housing type requested
When do you need housing?
Reason for seeking housing
(prompt examples: homelessness, instability, safety concerns, recovery support, affordability, relocating)
Current housing status
Length of housing instability
SECTION 3 — Supportive Housing Fit
Comfort with shared living?
Willing to participate in supportive services such as, counseling, case management, job training, life skills development, etc.?
Please let us know if you are involved in any of the following:
If you answered yes to the question above, please explain.
Do you have any medical conditions/concerns?
If yes, please explain. (List medications if any.)
Have you ever received a professional diagnosis for any mental health conditions?
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.

Currently receive ADL assistance?
If yes, who provides assistance?
SECTION 5 — Support Services & Needs
Currently work with any of the following? (Multiple Choice)
Accessibility or accommodation needs?
Currently in treatment or recovery support?
SECTION 6 — Income & Community Fee
Monthly income range
Income source (Multiple Choice)
Ability to pay required community fee
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?
Short paragraph explanation if yes
Criminal history?
Short paragraph explanation if yes
Are you currently on probation?
Short paragraph explanation if yes
Do you have an open DCF case?
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
Violence-free, drug-free environment agreement
SECTION 8 — Community Expectations (Yes/No)
Mark if you agree to the following
SECTION 9 — Final Questions & Signature
How did you hear about us?
Anything else we should know?
Electronic Signature
Date Signed

MonthDayYear
Should be Empty:

SECTION 1 — Applicant Information