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
Referral Source
*
Self
Family/Friend
Case Manager
VA-HUD VASH
Hospital
Agency
Other
Emergency Contact
Primary Contact Name
*
First Name
Last Name
Relationship
*
Secondary Contact Name
First Name
Last Name
Relationship
Housing Needs & Priority
How urgent is your need for housing?
*
Immediate (within 1 week)
Within 1 month
Within 3 months
Flexible (no immediate need)
Current Housing Search Status
*
Actively seeking
Planning ahead
Exploring
Current Living Situation
*
Homeless
Shelter
Couch Surfing
Renting
Other
Preferred Move-In Date:
*
-
Month
-
Day
Year
Date
Room Preference
*
Shared
Private
No Preference
Preferred housing environment
*
Men-Only
Women-Only
Co-ED
Open to Either
Able to Pay $750-$1,500 per Month?
*
Yes
No
Currently Employed?
*
Yes
No
Monthly Income
*
Please Select
$900+
$700-$899
$500-$699
Under $500
Do you currently have reliable personal transportation?
*
Yes
No
Do you need housing near public transportation?
*
Yes
No
What is your comfortable walking distance to public transportation?
*
0-5 minutes
6-10 minutes
11-20 minutes
20+ minutes
Are you able to provide a standard deposit approximately equal to one month’s community fee?
*
Yes
No
Not at this time
Expected length of stay?
*
1 Year +
6-12 Months
3-6 Months
1-3 Months
Unsure
Income and Benefits
Primary Source Of Income
*
Employment
SSI
SSDI
VA Benefits
SNAP
Retirement
Consistent Monthly Income?
*
Yes
No
Independent Living Capacity
Able to Live Independently Without Daily Supervision?
*
Yes
No
Need Help with Medication?
*
Yes
No
Need Help with Transportation?
*
Yes
No
Need Help with Cooking?
*
Yes
No
Need Help with Hygiene?
*
Yes
No
Manage Own Medication?
*
Yes
No
Not Applicable
Medical Condition to Disclose (if applicable)
Background
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
Lifestyle & Roommate Preferences
How Would You Describe Yourself?
*
Quiet
Active
Other
Preferred Roommate Gender (if applicable)
*
Male
Female
N/A
Willing to Comply With All House Rules and Community Standards?
*
Yes
No
Do You Have Any Pets?
*
Yes
No
References
Reference Name & Phone Number (Optional)
Additional Information
Reason for Seeking Housing
*
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 application does not guarantee placement.
Signature
Date
-
Month
-
Day
Year
Date
Final Priority Score
Calculation
Application Status
Submit Intake
Submit Intake
Should be Empty: