She Elevates Community: Pre Screening/ Wait List Form
We are excited to learn about you! Please fill out this form, and our team will reach out when housing becomes available.
Name
*
First Name
Last Name
*
-
Area Code
Phone Number
Submit
Email
*
example@example.com
Date of Birth
*
Housing Preference
*
Shared Room
Private Room
No Preference
Guaranteed Income Source:
*
SSI
SSDI
Retirement
Employment
other
Total Monthly Income amount?
*
$
When will funds be available
*
Today
48 hrs.
a week (7days)
Next Benefit date
Need invoice
not sure
Support Needed
*
SNAP/Medicaid
ID Help
Job Readiness
Peer Support
Please select any that apply to your current situation:
*
Veteran
Returning Citizen (formerly Incarcerated)
Experiencing Homelessness or Housing Instability
Survivor of Domestic Violence
Low-income or fixed income
other
Where are you staying right now:
*
Shelter
Treatment Facility
Hospital
Jail/Prison release
With Family/Friends
Street
other
Do you have a Case Manager/ Social Worker
*
Please Select
Yes
No
Please tell us a little about yourself, and medical, mobility, personal needs or support you many require, and why you are interested in joining She Elevates Community:
*
Referral Source
*
Ex: Agency, social media, etc
She Elevates Restoration Home
Thank you for your interest in She Elevates Restoration Home. We appreciate you reaching out to join our community. A member of our team will follow up with you when space becomes available of if any additional information is needed to move forward.
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