Participant Pre-Screening & Intake Application
Please provide your details to help us assess and prioritize your housing application.
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
MM-DD-YYYY
Gender
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Address/Living Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have children who would be living with you?
*
Yes
No
How many children would be living with you?
*
Ages of Children
*
Current Housing Situtation
Where are you currently staying?
*
Renting
Living with Family/Friends
Shelter
Hotel/Motel
Hospital/Rehabilitation Facility
Homeless
Other
How soon do you need housing?
*
Immediately (24-48 hours)
Within 7 Days
Within 30 Days
More Than 30 Days
Emergency Contact
Primary Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Housing Preferences
Preferred housing environment
*
Men’s Home
Women’s Home
Family Home (if applicable)
Co-ED
No Preference
Room Preference
*
Shared
Private
No Preference
Income & Funding
Primary Source Of Income (Select all that apply)
*
Employment
SSI
SSDI
VA Benefits
Retirement Income
Child Support
Other
Please Describe
*
Estimated Monthly Income
*
Please Select
Under $750
$750-$999
$1,000-$1,499
$1,500-$1,999
$2,000-$2,499
$2,500-$2,999
$3,000 +
How will you be paying for housing?
*
Please Select
I will pay myself using my income.
A family member or friend will help pay.
An agency or organization will pay.
I have a housing voucher or rental assistance.
I’m not sure yet.
What program are you approved through?
*
Do you currently have funds available for move-in costs?
*
Yes
No
Not Sure
Expected length of stay?
*
1 Year +
6-12 Months
3-6 Months
1-3 Months
Unsure
Program Eligibility
Are you able to manage your own daily living activities independently? Examples: Bathing, Dressing, Medication Management, Mobility
*
Yes
No
Are you ambulatory and able to move around independently?
*
Yes
No
Do you require ongoing medical or personal care services?
*
Yes
No
Please Explain
*
Medical Condition to Disclose (if applicable)
Referral Source
Referral Source
*
Self
Family/Friend
Agency/Nonprofit
Hospital/Healthcare Provider
Veteran Services Program
Government Program
Faith-Based Organization
Community Organization
Other
Social Worker/Discharge Planner Name
*
Program Name (VA-HUD VASH, SSVF, etc.)
*
Contact Name
*
Agency Name
*
Case Manager Name
*
Program Name
*
Referring Person’s Name
*
Hospital/Organization Name
*
Agency/Organization Name
*
Phone Number
*
Email
Screening
Have you ever lived in shared housing before?
*
Yes
No
Are you willing to follow house rules, chore schedules, quiet hours, visitor guidelines, and community expectations?
*
Yes
No
Prior Evictions?
*
Yes
No
Criminal Background?
*
Yes
No
Registered Sex Offender?
*
Yes
No
Pending Legal Matters?
*
Yes
No
History of Substance Abuse?
*
Yes
No
Do You Smoke?
*
Yes
No
Do You Have Any Pets?
*
Yes
No
Additional Information
What is prompting your housing search today?
*
Please share any additional information or special circumstances that may help us assess your housing needs.
Applicant Certification
I certify that the information provided is true and complete to the best of my knowledge. I understand that submission of this intake form does not guarantee placement.
*
Yes
No
Date
-
Month
-
Day
Year
Date
Participant Score
Immediate Review
High Priority
Standard Review
Needs further Assessment
Application status
Submit Intake
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