Independent Housing Pre-Screening / Intake Form
This form helps us assess eligibility and determine the most appropriate housing placement. All information is confidential and used solely for placement purposes.
Section 1: Applicant Information
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Source
Agency
Case Manager
Hospital
Outreach Worker
Family/Friend
Self Referral
Other
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Section 2: Income & Benefits
This information helps determine eligibility for housing program.
Do you have a steady source of income?
Yes
No
Primary Source(s) of Income
SSI
SSDI
VA Benefits
Retirement/Pension
Other
Estimated Monthly Income
Do you receive SNAP/EBT (Food Stamps) ?
Yes
No
Do you have a working phone we can reliably contact you on?
Yes
No
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Section 3: Independent Living Capacity
This section helps us understand the level of support that may be helpful for you.
Are you able to live independently without daily assistance?
Yes
No
Do you currently receive assistance with daily activities(cleaning, cooking, hygiene, transportation, etc.)
Yes
No
If yes, please explain the assistance you receive
Are you currently prescribed any medications?
Yes
No
Do you experience difficulty accessing medications?
Yes
No
If yes, please explain
Do you require reminders for medications and appointments?
Yes
No
Do you have any mental health diagnoses you would like us to be aware of?
Yes
No
If yes, please explain
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Section 4: Housing Preferences & Accessibility Needs
Please let us know your housing preferences and accessibility needs.
Preferred Room Type **Please note that all common areas of the home (such as the kitchen, living room, and bathrooms) are shared by all residents**
Shared Room
Private Room
No Preferences
Preferred Move-In Date
-
Month
-
Day
Year
Date
Do you have any physical disabilities or mobility limitations?
Yes
No
If yes, please explain
Do you require a ground-floor or downstairs room?
Yes
No
Do you have reliable transportation?
Yes
No
If no, do you need housing near a public bus route?
Yes
No
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Section 5: Background & Legal History
These questions help us determine eligibility for certain housing programs.
Have you ever been evicted?
Yes
No
Have you even been convicted of a felony?
Yes
No
Are you currently registered as a sex offender?
Yes
No
Do you have any pending legal matters or court cases?
Yes
No
If yes, please explain
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Section 6: Lifestyle & House Expectations
These questions help ensure a safe and respectful living environment.
Are you willing to comply with house rules (no drugs, no unapproved guests, cleanliness standards, quiet hours, respect for others)?
Yes
No
Do you smoke or vape?
Yes
No
Do you consume alcohol?
Yes
No
Do you have any pets?
Yes
No
How would you describe your cleanliness level?
Very Clean
Average
Needs improvement
Do you have any difficulty sharing space with others?
Yes
No
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Section 7: Additional Information
Why are you seeking housing at this time?
Is there anything else you would like us to know to help with placement?
Emergency Contact (Optional but recommended)
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Upload Supporting Documents (optional)
Browse Files
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Choose a file
Accepted files may include ID, benefit letters, proof of income, or other placement-related documents.
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I confirm that the information provided is true and complete to the best of my knowledge.
*
Yes
Submit Housing Application
Date of Birth
-
Month
-
Day
Year
Date
Should be Empty: