Pre-Screening Form

Pre-Screening Form

Please provide your basic information below.
Full Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How were you referred to New Chapter Living?*

SelfFamily/FriendCase ManagerAgencyOnline SearchOther
Income & Financial Stability
Do you have a steady source of income?*

YesNo
Primary source of income:*

EmploymentSSISSDIVA BenefitsRetirement IncomeOther
Estimated monthly income:*
Proof of income may be requested.
Do you receive SNAP/EBT benefits?*

YesNo
Do you have a working phone we can use to contact you?*

YesNo
Are you able to pay rent on time each month?*

YesNo
Independent Living Ability

New Chapter Living provides independent housing only.
Are you able to live independently without daily assistance or supervision?*

YesNo
Are you able to manage your medications independently (if applicable)?*

YesNoNot Applicable
Do you currently require assistance with daily living activities (cleaning, cooking, hygiene, etc.)?*

YesNo
If yes, please explain:*
Enter N/A if not applicable to you
Independent Living Acknowledgement:
I understand that New Chapter Living provides independent residential housing only and does not provide medical care, personal care, supervision, or supportive services.*

YesNo
Housing Preferences
What type of room are you seeking?*

Shared RoomPrivate RoomPrivate Room with Private BathroomNo Preference
Desired Move-In Date:*

MonthDayYear
Date
Do you have any mobility concerns requiring specific accommodations?*

YesNo
If yes, please describe:*
Enter N/A if not applicable to you
Background Screening
Have you ever been evicted from a previous residence?*

YesNo
If yes, please explain:*
Enter N/A if not applicable to you
Have you ever been convicted of a felony?*

YesNo
If yes, please briefly explain:*
Enter N/A if not applicable to you
Are you a registered sex offender*

YesNo
Community Expectations

New Chapter Living maintains a respectful, structured living environment.
Are you willing to follow house rules (no illegal drugs, no unapproved guests, quiet hours, cleanliness standards, etc.)?*

YesNo
Do you smoke?*

YesNo
Do you have any pets?*

YesNo
Have you previously lived in shared housing?*

YesNo
If yes, how was your experience?*
Enter N/A if not applicable to you
Property Policies
Do you understand that security cameras are installed in common and exterior areas and that monthly property inspections are conducted?*

YesNo
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Final Questions
Why are you seeking housing at this time?*
Is there anything else you would like us to know?*
Applicant Certification

I certify that the information provided in this pre-screening form is accurate and complete to the best of my knowledge. I understand that submission of this form does not guarantee housing placement.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Pre-Screening Form

Income & Financial Stability

Independent Living Ability

Independent Living Acknowledgement:

Housing Preferences

Background Screening

Community Expectations

Property Policies

Emergency Contact

Final Questions

Applicant Certification