Housing Needs Assessment Form

Participant Pre-Screening & Intake Application

Please provide your details to help us assess and prioritize your housing application.
- Name
  
  First NameLast Name
- Date of Birth *
  MM-DD-YYYY
- Gender*
- Phone Number
  Please enter a valid phone number.
- Email
  example@example.com
- Current Address/Living Location
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Referral Source*
  
  SelfFamily/FriendCase ManagerVA-HUD VASHHospitalAgencyOther
- Primary Contact Name*
  
  First NameLast Name
- Relationship*
- Secondary Contact Name
  
  First NameLast Name
- Relationship
- How urgent is your need for housing?*
  
  Immediate (within 1 week)Within 1 monthWithin 3 monthsFlexible (no immediate need)
- Current Housing Search Status*
  
  Actively seekingPlanning aheadExploring
- Current Living Situation*
  
  HomelessShelterCouch SurfingRentingOther
- Preferred Move-In Date:*
  
  MonthDayYear
  Date
- Room Preference*
  
  SharedPrivateNo Preference
- Preferred housing environment *
  
  Men-OnlyWomen-OnlyCo-EDOpen to Either
- Able to Pay $950-$1,200 per Month?*
  
  YesNo
- Currently Employed?*
  
  YesNo
- Monthly Income*
- Do you currently have reliable personal transportation?*
  
  YesNo
- Do you need housing near public transportation? *
  
  YesNo
- What is your comfortable walking distance to public transportation?*
  
  0-5 minutes6-10 minutes11-20 minutes20+ minutes
- Are you able to provide a standard security deposit (approximately equal to one months rent)?*
  
  YesNoNot at this time
- Expected length of stay?
  
  1-3 months3-6 months6+ monthsUnsure at this time
- Type a question*
  
  EmploymentSSISSDIVA BenefitsSNAPRetirementOther
- Consistent Monthly Income?*
  
  YesNo
- Able to Live Without Daily Supervision?*
  
  YesNo
- Assistance Required (if any)*
  
  MedicationTransportationHygieneCookingCleaningNone
- Manage Own Medication?*
  
  YesNoNot Applicable
- Medical Condition to Disclose (if applicable)
- Prior Evictions?*
  
  YesNo
- Criminal Background?*
  
  YesNo
- Registered Sex Offender?*
  
  YesNo
- Pending Legal Matters?*
  
  YesNo
- History of Substance Abuse?*
  
  YesNo
- Do You Smoke?*
  
  YesNo
- How Would You Describe Yourself?*
  
  QuietActiveOther
- Preferred Roommate Gender (if applicable)*
  
  MaleFemaleN/A
- Willing to Comply With All House Rules and Community Standards?*
  
  YesNo
- Do You Have Any Pets?*
  
  YesNo
- Reference Name & Phone Number (Optional)
- Reason for Seeking Housing*
- Please share any additional information or special circumstances that may help us assess your housing needs.
- I certify that the information provided is true and complete to the best of my knowledge. I understand that submission of this application does not guarantee placement.
- Signature
- Date
  
  MonthDayYear
  Date
- Internal Priority Score
- STATUS
Should be Empty:

Participant Pre-Screening & Intake Application