• Housing Interest & Intake Form

    Housing Interest & Intake Form

  • Section 1 : Applicant Information

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

  • Section 2 : Current Housing Status

  • 1. What best describes your current housing situation?*
  • 2. How long have you been without stable housing?*
  • 3. Are you seeking transitional housing while working toward independent housing?*
  • 4. Are you seeking long-term co-living housing?*

  • Section 3 : Program Readiness

    Please answer honestly to help us determine program fit.
  • 1. Are you willing to live in a structured housing program with rules and expectations?*
  • 2. Are you willing to participate in goal setting, or support services?*
  • 3. Are you able to live in a co-living housing environment if required?*
  • 4. Are you willing to remain drug-free while participating in the program?*

  • Section 4 : Income & Employment

  • 1. Are you currently employed?*
  • 2. Do you have any source of income?*
  • 3. If yes, what type?*

  • Section 5 : Background Screening (Confidential)

    (This information is used for placement andsafety purposes only.)
  • 1. Are you currently on probation or parole?*
  • 2. Do you have any open warrants?*
  • 3. Do you have a history of violent offenses?*
  • 4. Are you legally able to reside in community housing?*

  • Section 6 : Support Needs

  • *

  • Section 7 : Personal Goals

  • Section 8 : Referral Information

  • *

  • 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.

  • 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.

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