Shared Housing Stabilization Prescreening Application

GENTLE HELPERS CONNECTIONS PLACEMENT AND REFERRAL AGENCY
Shared Housing Stabilization Prescreening Application
Gentle Helpers Connections is currently accepting prescreening applications only for independent living and co-living housing programs. Please complete this brief form to help us determine whether one of these housing pathways may be appropriate for you. Your responses will help our office review your household composition, income stability, housing preferences, affordability, and readiness to move before coordinating possible next steps. Independent living and co-living programs generally require applicants to have verifiable income or another reliable source of payment and to be able to live independently without on-site personal care, medical care, behavioral-health treatment, or daily supervision. Please note: Gentle Helpers Connections does not provide emergency housing, shelter placement, crisis housing, rental assistance, or guaranteed housing placement. Submitting this form does not guarantee acceptance, approval, housing availability, or placement. Each independent housing provider establishes its own eligibility requirements, screening process, fees, household guidelines, and final admission decisions. If you are experiencing a homelessness emergency or need immediate shelter assistance, call 311 or 211 and request emergency housing or Coordinated Entry System assistance. You may also visit a designated Coordinated Entry System intake location in the City of Chicago. Please submit this form only once. Duplicate submissions may delay the review process. To update information you previously submitted, contact our office at info@gentlehelpershomecare.com instead of completing another application.

This form takes approximately 3 minutes to complete.
1. Are you currently receiving support from a case manager, social worker, discharge planner, referral agency, organization, or supervising officer?
Referral Source

Agency Information
1a. Referral Contact Name

First NameLast Name
1b. Referral Contact Title
1c. Referral Contact Number
Format: (000) 000-0000.
1d. Referral Contact Email address
example@example.com
1e. Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1f. Referral Details: Please provide as much detail as possible about the applicant’s current housing situation, referral reason, urgency of need, known housing barriers, behavior concerns, deadlines, and any relevant safety or stabilization concerns. Please also include whether your agency has served this applicant in the past and share any relevant history, prior engagement, service outcomes, or concerns that may help our office better evaluate the referral and identify appropriate housing navigation options.
Reasons for Referral
SECTION 1 - Applicant Contact Information
1. Applicant's Legal Name (as shown on government-issued ID)

First NameLast Name
2. Applicants Best Contact Number
Primary phone number for housing coordinationFormat: (000) 000-0000.
3. Email Address
example@example.com
4. Current Age
(numbers only)
5. Gender
SECTION 2 - Location & Geographic Data
6. Current or Last Known ZIP Code
numbers only
7. Preferred Chicago Neighborhood, Chicago Suburb or Northwest Indiana area
(Example: Southside, Westside, Northside, Surburbs
SECTION 3 - Household Composition
8. Current Housing Situation
9. Are you applying for:
10. Total Household Size
Enter a number only
SECTION 4 - Income
10. What are your current sources of income? (Select all that apply)
12. Do you currently have a housing voucher or rental assistance?
13. If you have a voucher, what type of voucher or rental assistance?
11. Approximate total monthly household income
numbers only, no commas.
15. Do you currently have a housing voucher?
SECTION 5 - Housing Readiness Indicators
15. Do you have move-in funds available?
12. How much in move-in funds do you have available?
numbers only no commas
16. Any eviction filed within the last 5 years?
17. Estimated Credit Score Range - Estimated Credit Score Range (Best Estimate)
SECTION 6 - Housing Preference
13. Desired move timeline
14. Desired housing type
15. Are you open to independent living or co-living housing?
16. If there is additional information that may assist us in coordinating your housing search (such as accessibility needs, mobility considerations, work schedule, preferred location, or other important factors), you may share it below.For your protection, please do not include confidential medical details or sensitive personal information in this section.

0/500
17. Are there any housing restrictions or background consideration that may affect the housing provider's screening?
Acknowledgement & Consent

Gentle Helpers Connections provides housing navigation, referral, and placement coordination services. We are not a landlord, property manager, housing authority, emergency shelter, or financial assistance program. Final application, approval, and housing placement decisions are made solely by independent landlords and third-party housing providers. Due to the high volume of requests for housing assistance, newly submitted prescreening applications are currently being placed on a waitlist. Applications will be reviewed in the order received and as staff capacity and potentially suitable housing opportunities become available. Submission of this form does not guarantee an immediate response, referral, housing availability, lease approval, or placement. Information submitted through this form is used only for housing prescreening, referral coordination, communication, and internal tracking purposes. Gentle Helpers Connections does not sell personal information. Information may be shared with housing providers or referral partners only when necessary to explore or coordinate a potential housing opportunity. Please do not submit Social Security numbers, copies of identification, bank statements, financial account information, or confidential medical records through this form unless specifically requested at a later stage through an appropriate process. By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that my application may be placed on a waitlist and that housing is not guaranteed. I also consent to being contacted by Gentle Helpers Connections by telephone, text message, or email regarding my prescreening application and possible housing coordination.
Should be Empty:

GENTLE HELPERS CONNECTIONS PLACEMENT AND REFERRAL AGENCY

Shared Housing Stabilization Prescreening Application

Referral Source

SECTION 1 - Applicant Contact Information

SECTION 2 - Location & Geographic Data

SECTION 3 - Household Composition

SECTION 4 - Income

SECTION 5 - Housing Readiness Indicators

SECTION 6 - Housing Preference

Acknowledgement & Consent