Housing Interest & Intake Form

Housing Interest & Intake Form
Section 1 : Applicant Information
Full Legal Name*

First NameLast Name
Preferred Name (if different)

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (if available)
example@example.com
Current Living (Situation Address (or city/state if unhoused)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section 2 : Current Housing Status
HomelessStaying with family or friendsShelter or transitionalhousingCorrectional facilityOther
Other:
Less than 30 days1–3 months3–6 monthsMore than 6 months
YesNo
YesNo
Section 3 : Program Readiness

Please answer honestly to help us determine program fit.
YesNo
YesNo
YesNo
YesNo
Section 4 : Income & Employment
Full-timePart-timeUnemployedActively seeking employment
YesNo
EmploymentSSI / SSDI/VA IncomePublic AssistanceOther
Other:
Section 5 : Background Screening (Confidential)

(This information is used for placement andsafety purposes only.)
YesNo
YesNo
YesNo
YesNo
Section 6 : Support Needs
Housing stabilityEmployment supportLife skills developmentFinancial education /budgetingRe Entry supportOther
Other:
Section 7 : Personal Goals
1. What are you hoping to gain from this program?*
2. What does independent living mean to you?*
Section 8 : Referral Information
Self-ReferralSocial Worker / Case ManagerCourt / ProbationCommunity OrganizationFriend / FamilyOther
Other:
Section 9: Applicant Acknowledgment
I understand that submitting this intake form does not guarantee acceptance into the program. I certify that the information provided is accurate to the best of my knowledge.
Signature*
Date*

MonthDayYear
Date
What Happens Next?

If you appear to be a good fit, a team member will contact you to discuss next steps, including a full application and interview.
Should be Empty:

Housing Interest & Intake Form

Section 1 : Applicant Information

Section 2 : Current Housing Status

Section 3 : Program Readiness

Section 4 : Income & Employment

Section 5 : Background Screening (Confidential)

Section 6 : Support Needs

Section 7 : Personal Goals

Section 8 : Referral Information

Section 9: Applicant Acknowledgment