Housing Waitlist Pre-Screening Application
Submit your information to join the waitlist for housing consideration. Please answer all required questions honestly and completely.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current Location (City, State / Province)
*
Are you currently on supervision?
*
Yes
No
Who referred you? (Caseworker/Agency Name)
*
Are you willing to share a room?
*
Yes
No
Maybe
What is your monthly income amount? (USD)
*
Income Source (Check all that apply)
*
Employment
Disability Benefits
Social Security
Unemployment
Family Support
No Income
Other
Do you have a valid ID, SSN, and Proof of income?
*
Yes
No
Some, but not all
Have you ever been convicted of a violent or sexual offense?
*
Yes
No
If yes, please explain:
Are you currently facing any pending legal charges?
*
Yes
No
If yes, please explain:
Have you ever been diagnosed with a mental health condition?
*
Yes
No
If yes, do you have a treatment or medication plan in place?
Yes
No
Not applicable
Are you currently receiving counseling or support services?
*
Yes
No
Have you struggled with substance use in the past?
*
Yes
No
Are you currently sober?
*
Yes
No
If yes, how long?
When are you looking to move in?
*
-
Month
-
Day
Year
Date
How did you hear about New Pathway Living?
Join Waitlist
Should be Empty: