• KDG Housing Pre-Screening Intake Form

    A brief, intake form to assess your housing needs and fit.

  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Referral Source

  • Are you completing this application for yourself or on behalf of someone else?*

  • Housing Need & Urgency

  • What is your current housing situation?*
  • How soon do you need housing?*

  • Payment / Funding Source

  • How do you plan to pay for housing?*

  • Income & Ability to Pay

  • Do you have the ability to pay a monthly rent or program fee?*

  • Shared-Living Fit & Conduct

  • Are you interested in independent housing, shared living, or either?*
  • Have you lived with roommates or in a group setting before?
  • What is your comfort level with sharing common spaces (kitchen, living room, etc.)?*
  • Are you able to follow shared living guidelines (such as noise, cleanliness, and respect for others)?*

  • Independent Living Ability

  • Are you able to independently manage daily self-care (such as bathing, dressing, taking medications as needed, etc.)?*
  • Are you able to prepare simple meals for yourself?*
  • Are you able to keep your living space reasonably clean?*
  • Are you able to manage your own schedule (appointments, daily routines, etc.)?*

  • Safety & Background

  • Have you ever been asked to leave a housing program or group living situation?
  • Do you have any current legal restrictions that would affect your housing eligibility (for example, court-ordered restrictions on where you can live)?

  • Support & Accommodation

  • Daily Practical Information

  • Do you smoke or vape?
  • Do you have pets or service animals?
  • Do you need any reasonable accommodation to safely participate in shared housing?
  • Are you currently receiving Medicaid Waiver services?
  • Do you have a case manager or support worker?
  • Do you have an animal?
  • Do you currently have any active collections or judgments?
  • Do you have a representative payee?
  • Do you have any criminal convictions?
  • Are you currently on probation or parole?
  • Is there any current conflict, safety concern, or restraining order situation we should be aware of for placement safety?
  • Who will be responsible for payment?
  • Is funding already approved?

  • Communication Consent

  • Do you consent to be contacted by KDG Housing regarding your intake form?*
  • What is your preferred method of communication?

  • By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this intake from does not guarantee placement in KDG Housing.

  • Applicant Acknowledgment

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: