-
-
- Date of Birth*
-
Format: (000) 000-0000.
-
-
-
-
Format: (000) 000-0000.
-
-
-
-
-
Format: (000) 000-0000.
-
- Can KDG Housing contact the referral source about your housing need?
-
- What date do you need housing?
- Are you currently at risk of sleeping outside, in a car, or in an unsafe location?
- Do you need emergency placement within 24-72 hours?
-
- Who will be responsible for payment?*
- Is funding already approved?*
-
- How long will the funding cover?*
- Can the first payment and any required community/program fee be paid before move-in?*
-
-
- Employment Status*
-
-
- Can you pay rent on time each month?*
- Do you have a representative payee?*
-
- What is the main reason you need housing?
-
- Current Status*
-
- Reason for seeking new housing*
-
- Have you rented before?*
-
- Do you have any unpaid rent or balances owed?*
- Have you lived in a shared/group setting before?*
-
- Expected move-in date
- Required Income Verification (select all that apply)
- Do you prepare your own meals?*
- Can you manage your own medications without reminders?*
- Can you handle personal hygiene and self-care?*
- Can you use public transportation or arrange your own rides?*
- Can you manage your own schedule and appointments?*
- Can you communicate your needs to staff or others?*
- Can you handle basic household chores (cleaning, laundry)?*
- Can you make decisions about your daily routine independently?*
- Can you handle a minor emergency (call 911, contact staff) on your own?*
-
- Do you have a documented disability?*
-
- Are you currently receiving Medicaid Waiver services for personal care?*
- If yes, what type of waiver assistance do you receive?
-
- Are you currently receiving mental health services?*
-
- Do you have a case manager or support worker?*
-
- Are you currently on medication?*
- Can you manage your medications independently?*
- Have you had a psychiatric hospitalization in the last 12 months?*
-
- Do you have a history of self-harm or harm to others?*
-
- Have you had issues with drug or alcohol use?*
- Are you currently in recovery?*
- Are you willing to comply with a zero-tolerance substance policy?*
- Do you currently have any active collections or judgments?*
-
- Have you received public benefits (HUD, Section 8, TANF, etc.)?*
- Do you have a bank account?*
- How do you typically pay bills? (Select all that apply)
- Have you had a housing voucher (Section 8, HUD, etc.) in the past?*
- Do you have any criminal convictions?*
-
- Are you currently on probation or parole?*
-
- Do you have any sex offender registration requirements?*
- Are you comfortable in a shared living environment?*
- Are you comfortable sharing a bedroom?*
- Do you smoke cigarettes or tobacco?*
- Do you have pets?*
- Do you have a vehicle?*
- Do you agree to the above rules and expectations?*
-
- Date*
- Which location are you looking to move to?*
-
- Should be Empty: