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
Submit Application
Should be Empty: