Housing Waitlist Form
*Please complete all fields
Name
*
First Name
Last Name
Date of Birth
*
Ā -
Month
Ā -
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Gender
*
Male
Female
Non-binary
Which best describe you?
*
Veteran
Elderly
Adult needing affordable housing during a rough time
Other
If other, Please Explain
š¾ Do you have a service animal or emotional support animal? Please note: Documentation may be required accommodation.
*
Yes
No
Do you have children that will need to live with you?
*
Yes
No
If yes, How Many?
1
2
3
More than 3
What are their ages?
Are you willing to live in a shared, drugā and alcoholāfree environment?
*
Yes
No
Are you independent? Can you care for yourself and manage daily routines?
*
Yes
No
Do you have your own means of transportation?
*
Yes
No
We do not provide medical care or assistance with daily living activities. All clients must be independent.
*
I understand that no medical assistance is provided.
Do you smoke?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you have a support team (family, caseworker, etc.)?
*
Yes
No
Do you have a Mental health Diagnosis?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
Have you ever been convicted of a crime?
*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
Tell us about yourself.
*
Were you referred to us by an agency? If so, please provide the name of the agency.
Preferred Move- In Timeframe
Immediately
1-2 Weeks
30 days
Not sure
Monthly Income
*
How Do You Plan to Pay for Housing?
SSI/SSDI
Self Pay
Family Support
Case Manager
File Upload
Upload Income Verification
Upload
*
Today's Date
*
Ā -
Month
Ā -
Day
Year
Date
I confirm that the above information is accurate, and I understand someone will contact me within 48 hours.
*
Yes
Final Note: Submitting this form does not guarantee housing. All applications are reviewed, and eligible individuals will be contacted when a space becomes available.
I Understand
Submit
Should be Empty: