ENVISION PRESCREENING APPLICATION
Taking the first step toward a stable and independent future starts here. Please note that this is an application for the WAITLIST and does not guarantee acceptance into the housing program. Once your application has been submitted, a member of the Envision Enterprises team will reach out within 1-2 business days to discuss the next steps.
First Name
*
Last Name
*
Gender at birth
*
Female
Male
Birthdate
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Name of Emergency Contact and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
Please Select
Homeless
Staying with friends/family
Rental housing
Shelter
Transitional housing
Other
Referral Source
*
Please Select
Self
Community agency
Healthcare provider
Family/Friend
Other
Do you have any mental health diagnosis?
*
Please Select
Yes
No
Prefer not to say
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
Do you attest that you will fully comply with all program policies and house rules at all times?
*
Yes, I will
No, I won't
What is your source of verifiable income ?
*
Please Select
SSI
SSDI
Pension
VA Benefits
Community Program Pay
Unemployment
Other
Preferred move-in date
-
Month
-
Day
Year
Date
Consent and Acknowledgement
I certify that the information provided is accurate and true. I understand that this information is confidential and is solely used to determine eligibility for housing with Envision Enterprises.
Submit Application
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