Pre - Screening Questionaire
To determine your eligibility for Independent Shared Housing
What is your source of income?
Employment
SSI/SSDI
Veteran's Assistance
Other
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How much is your monthly income?
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When are you looking to move in?
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Month
-
Day
Year
Date
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What is the reason for placement?
Re-Entry
Disabled
Mental health
Transition
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Are you independent and able to care for yourself?
Yes
No
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Are you on probation or parole?
Yes
No
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Are you currently on any medications? If so, are you compliant?
Yes
No
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If you selected "Yes" to the previous question please list all medications. If "No" type "N/A"
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Have you lived in shared housing before?
Yes
No
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Who will be your point of contact moving forward? Ex. Case Managers, Emergency Contacts, etc.
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When can you pay your first month's program fee?
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Month
-
Day
Year
Date
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Please provide contact information. We will be in touch.
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