Independent Housing Interest & Intake Form
We’re here to help you take the next step toward stable housing.Please complete the information below so we can better understand your situation and determine if Sheltering Hearts is a good fit for your needs..
Full Legal Name
*
First Name
Last Name
Preferred Name (optional)
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City and State
*
Best way to contact you
*
Phone
Email
Text
Are you applying as:
*
Single woman
Mother with children
If you are a mother with children what are their ages:
What type of verifiable income do you have?
*
Income from job
Self Employed
SSI (Supplemental Security Income)
SSDI (Social Security Disability Insurance)
VA Benefits
Unemployment
Current housing status
*
Homeless (unsheltered)
Emergency Shelter
Transitional Housing
Temporarily staying with others
Other
How soon do you need housing?
*
Immediately
30 days
60-90 days
Have you lived in housing before?
*
Yes
No
Can you manage your own medications and personal hygiene independently?
*
Yes
No
Can you prepare your own meals?
*
Yes
No
Can you manage transportation on your own?
*
Yes
No
Do you smoke cigarretes?
*
Yes
No
Are you currently on drugs or alcohol?
*
Yes
No
Can you live in a shared home with house rules?
*
Yes
No
I understand this is independent housing only and not a medical, mental health or care facility.
*
I understand
I understand I am responsible for my own medical care, meals, transportation an daily needs.
*
I understand
How did you gear about us?
*
Case Manager
Non-Profit Organization
Social Media
211
Word of mouth
Other
I consent to being contacted regarding housing availability and assessment
*
I consent
Please describe your current situation and any immediate needs:
*
Any major health issues?
Anything else you'd like us to know?
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