Total Legacy Foundation Housing & Support Services Pre-Screening

Total Legacy Foundation Housing & Support Services Pre-Screening

Many women who reach out to us have been through difficult or unsafe situations. Please complete this application to help us assess your eligibility for housing or support services. All information remains confidential.
Applicant Information
What brought you to Total Legacy (i.e.: Are you looking for housing mainly because of recovery, a life transition, or leaving a difficult or unsafe situation?)
What personal belongings do you have with you right now?
Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Age*
YesNo
ID CardDriver's LicensePassportVA
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com
Have you received any mental health counseling, therapy, or related services in the past or currently? If yes, please describe.
What substance(s) have you struggled with in the past? Are you currently receiving any recovery or support services? If yes, where?
Are you currently taking any prescribed medications (for any health condition)? If yes, please list.
Are you currently working with any organizations, programs, or case managers? If yes, please provide the agency or program name and describe what type of support or resources they are helping you with.
Have you had any past charges or legal cases we should be aware of? If yes, please share the charge, where it occurred (city or county), and whether the case is resolved, dismissed, or still active.
Counselor's/Case Manager's?CO's Name
Counselor's/Case Manager's/CO's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
MedicaidState HealthOther
Have you ever lost housing in the past? If yes, how many times and what were the circumstances?
Please describe your work history for the past three years. Are you currently employed or looking for work?
Type of work (if applicable)
Are you planning to pursue any education, job training, or certification programs? If yes, please describe.
WorkingDOC Housing VoucherSSISSDIVASelf-Pay
Do you currently have any Legal Financial Obligations (LFOs), court-related fines, restitution, or other outstanding debts? If yes, please describe.
Emergency Contact 1: Name*
Emergency Contact 1: Relation*
Emergency Contact 1: Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 1: Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2: Name*
Emergency Contact 2: Relation*
Emergency Contact 2: Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact 2: Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Include person who referred you name and contact
Additional Comments
Should be Empty:

Total Legacy Foundation Housing & Support Services Pre-Screening

Applicant Information