Housing Pre Screening Application

Housing Pre Screening Application

Please complete this application to help us determine your eligibility and housing needs.
Full Name

First NameLast Name
Date of Birth (MM-DD-YYYY)

MonthDayYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you currently on supervision?
Who referred you? (Caseworker/Agency Name)
Are you willing to share a room?
What is your monthly income amount? (in USD)
Income Source (Check all that apply)

Other
Do you have a valid ID, SSN, and Proof of income?
Have you ever been convicted of a violent or sexual offense?
If yes, please explain:
Are you currently facing any pending legal charges?
If yes, please explain:
Have you ever been diagnosed with a mental health condition?
If yes, do you have a treatment or medication plan in place?
Are you currently receiving counseling or support services?
Have you struggled with substance use in the past?
Are you currently sober?
If yes, how long?
When are you looking to move in? (MM-DD-YYYY)

MonthDayYear
Date
How did you hear about Unified Living Retreat?
Should be Empty: