SOCIAL LINX GROUP CO-LIVING HOMES APPLICATION
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Best Time To Contact
Morning (9am - 12pm)
Afternoon (12pm - 5pm)
Evening (5pm - 8pm)
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Housing Status - Describe Below
Please Select Your Current Housing Situation
*
Homeless
Living With Someone
Recent Eviction
Other___________________
Preference Room Type
*
Shared
Private
Any
Have You Ever Lived In A Shared Living Environment With Others?
*
Yes
No
Is This A Temporary Housing Need?
*
Yes
No
If Yes, What Is Your Anticipated Length Of Stay: (e.g 3months, 6months, 9months)
*
Current Source Of Income
*
Employed
SSI
SSDI
OTHER
IF OTHER PLEASE EXPLAIN
Monthly Income Amount
*
Are you currently enrolled in any support services for mental health. Are you receiving Psychiatric Rehabilitation Services?
*
Yes
No
If yes to Mental Health / Psychotic Services Please Provide More Information
What Is Your Desired Move In Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: