Pre-Screening Application
Please complete this pre-screening form for Shiloh Family Home. All information will be kept confidential and used to determine eligibility.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current Location (City, State/Province)
*
Are You Currently On Supervision?
*
Please Select
Yes
No
Who Referred You? (Caseworker/Agency Name)
Are you willing to share a room?
*
Please Select
Yes
No
Maybe
What Is Your Monthly Income Amount (USD)
*
Income Source (Check All That Apply)
*
Employment
Disability Benefits
Social Security
Unemployment
Family Support
No Income
Other
Do You Have A Valid ID, SSN, And Proof Of Income?
*
Please Select
Yes
No
Some, But Not All
Have You Ever Been Convicted Of A Violent Or Sexual Offense?
*
Please Select
Yes
No
If Yes, Please Explain The Nature Of The Offense
Are You Currently Facing Any Pending Legal Charges?
*
Please Select
Yes
No
Have You Ever Been Diagnosed With A Mental Health Condition?
*
Please Select
Yes
No
Are You Currently Receiving Counseling Or Support Services?
*
Please Select
Yes
No
Have You Struggled With Substance Use In The Past?
*
Please Select
Yes
No
Are You Currently Struggling With Substance Use?
*
Please Select
Yes
No
Are You Currently Sober?
*
Please Select
Yes
No
When Are You Looking To Move In?
*
-
Month
-
Day
Year
Date
Are you planning on short term stay or long term stay?
Please Select
Short-Term
Long-Term
Stay Length
Please Select
Short term stay (1-5 months)
Long term stay (6+ months)
Are you Independent? Capable of moving around, doing things for yourself, without special care.
Please Select
Yes
No
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Emergency Contact Relationship
If none, type 'None'
Do you need assistance walking, washing, eating?
Walking
Washing
Eating
Taking medicine
Other
If other, please explain what you may need assistance with.
Submit Application
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