INDEPENDENT LIVING PRESCREEN / WAITLIST FORM
Full Name
Phone Number
Format: (000) 000-0000.
Email Address (optional)
example@example.com
Age
Gender:
Male
Female
Prefer not to say
Preferred Move-In Date
-
Month
-
Day
Year
Date
Housing Preference:
Shared Room
Private Room
Source of Income (check all that apply):
SSI / SSDI
Employment
Retirement
Agency Pay
Other
Can you verify this income?
Yes
No
Monthly Income Amount
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What is your monthly budget you are willing to pay for room rent?
When will funds be available for move-in?
Immediately
Within 1-2 weeks
Within 30 days
Not sure
Do you have a case manager?
Yes
No
If yes, Case Manager Name & Agency
Current Living Situation (check one):
Shelter
Treatment Facility
With Family or Friends
Currently Unhoused
Other
Please list any mental or physical health diagnoses that may impact housing or daily living
Are you fully independent in daily living activities (able to cook, bathe, manage personal care, and complete daily tasks without assistance)?
Yes
No
If no, please briefly explain what assistance is needed
ID Assistance
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SNAP / Benefits Assistance
Employment Support
Transportation Resources
Healthcare / Medicaid Assistance
Other:
Other
Briefly describe your situation and why you are seeking housing
How did you hear about this program?
Submit
Should be Empty: