Pre-Screening Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
current living situation?
If Homeless, How Long?
Income (SSI, SSDI, job, etc.)
SSI
SSDI
Other
If other, explain:
Ability to Work While on Assistance?
YES
NO
If no, explain:
Case Manager or Support Worker?
YES
NO
Medication Use?
YES
NO
Medication Management?
YES
NO
Convictions or Legal Issues?
YES
NO
Cigarette Use?
YES
NO
Substance Use?
YES
NO
Comfort with Shared Living
YES
NO
Pets?
YES
NO
Willingness to Follow House Rules?
YES
NO
Signature
Continue
Continue
Should be Empty: