Next Step Independent Living Prescreen / Waitlist Form
Housing program intake and waitlist form for collecting personal, housing, income, and support-need information from applicants.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Age
*
Gender
*
Please Select
Male
Female
Prefer not to say
Housing Preferences and Timing
Preferred Move-In Date
*
-
Month
-
Day
Year
Date
Housing Preference
*
Please Select
Shared Room
Private Room
When will funds be available for move-in?
*
Please Select
Immediately
Within 1–2 weeks
Within 30 days
More than 30 days
Not sure
Income Information
Source of Income
*
SSI/SSDI
Employment
Retirement
Agency Pay
Other
Can you verify this income?
*
Please Select
Yes
No
Monthly Income Amount
*
Monthly budget you are willing to pay for room rent
*
Case Manager Information
Do you have a case manager?
*
Please Select
Yes
No
Case Manager Name & Agency
Current Living Situation and Support Needs
Current Living Situation
*
Please Select
Emergency shelter
Treatment facility
With family or friends
Currently unhoused
Other
Mental or physical health diagnoses that may impact housing or daily living
Are you fully independent in daily living activities?
*
Please Select
Yes
No
If no, please briefly explain what assistance is needed
Support Needs
Help obtaining ID or vital documents
Help applying for SNAP/benefits
Employment support
Transportation resources
Healthcare/Medicaid assistance
Other
Application Narrative and Referral Source
Briefly describe your situation and why you are seeking housing
*
How did you hear about this program?
Submit
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