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..
About You
Full Legal Name
*
First Name
Last Name
Preferred Name (optional)
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Household and Housing Need
Are you applying as:
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Single woman
Mother with children
If you are a mother with children please list every person who would be living with you, including each child's age:
How soon do you need housing?
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Immediately
30 days
60-90 days
Current housing status
*
Homeless (unsheltered)
Emergency Shelter
Transitional Housing
Temporarily staying with others
Other
Income & Program Availability
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
Other verifiable income/ housing assistance
Monthly Income Amount
Are you able to provide documentation of your income:
Yes
No
Sheltering Hearts is a program-fee-based transitional housing program. Are you able to pay the applicable monthly program fee and move-in deposit?
Yes
No
I have a third party/agency assisting with payment
Independent Living & Shared Housing
Sheltering Hearts provides housing only and does not provide personal care, meal preparation, medication management, transportation, or other daily living assistance. Please answer the following questions so we can determine whether our housing program can appropriately meet your needs.
What types of housing have you lived in previously (select all that apply)
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Rented my own apartment or home
Lived with family or friends
Shared housing/ roommate setting
Transitional housing program
Emergency Shelter
Other
I have not previously maintained housing on my own
Please briefly tell us about your most recent housing arrangement and what led to it ending.
Are you able to manage your medications, personal hygiene, and other daily personal care needs without assistance from Sheltering hearts?
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Yes
No
Are you able to obtain and prepare your own meals without assistance from Sheltering Hearts?
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Yes
No
Are you able to arrange and manage your own transportation without assistance from Sheltering Hearts?
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Yes
No
How do you currently manage transportation?
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Personal Vehicle
Public Transportation
Family/Friends
Transportation Assistance Program
Other
Do you currently smoke or use tobacco or nicotine products?
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Yes
No
I understand that smoking is not permitted inside the Sheltering Hearts home.
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I undestand
Do you currently use alcohol, marijuana, or other substances
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Yes
No
Prefer to discuss privately
I understand that Sheltering Hearts has rules regarding alcohol and substance use on the property, and I agree to follow all program and house rules.
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I understand and agree
Are you comfortable living in a shared home and following established rules and community expectations?
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Yes
I have questions or concerns I would like to discuss
Are you comfortable sharing a bedroom with another participant, if applicable to your placement?
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Yes
I would like to discuss this
Acknowledgement & Consent
I understand that Sheltering Hearts provides shared housing and that placement may include sharing a bedroom with another participant or family
*
I understand and agree
I understand this is independent housing only and not a medical, mental health or care facility.
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I understand
I understand I am responsible for my own medical care, meals, transportation an daily needs.
*
I understand
For mothers: I understand that parents are responsible for the supervision, care, transportation, meals, and needs of their children while participating in the program.
I understand
I consent to being contacted regarding housing availability and assessment
*
I consent
How did you hear about us?
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Case Manager
Non-Profit Organization
Social Media
211
Word of mouth
Other
Tell Us About Your Housing Needs
Please tell us about your current housing situation, what has led you to seek housing at this time, and any immediate needs you would like us to know about
*
Health, Safety & Accommodation Needs
Do you have any health, behavioral health. mobility or other needs that Sheltering Hearts should be aware of when considering your housing placement, room assignment, safety, or reasonable accommodations?
Anything else you'd like us to know?
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