Participant Information
Bridgeway housing application
Participant Intake & Enrollment Application
Complete this form to apply for housing and program participation.
Date of Intake
*
-
Month
-
Day
Year
Date
Referral Agency / Name of Referrer
Participant Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Social Security Number Last 4 Digits
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Male
Female
Non-binary
Prefer not to say
Emergency Contact Name
*
Relationship to Participant
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Living Situation and Referral Source
Current living situation
*
Homeless
Couchsurfing / Staying with others
Transitional Housing
Jail/Prison Release
Hospital / Rehab
Other
If other, please specify
Referral source
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Agency name
Referring contact name
First Name
Middle Name
Last Name
Referring contact phone
Please enter a valid phone number.
Format: (000) 000-0000.
Referring contact email
example@example.com
Housing Need, Medical, and Mental Health History
Brief summary of your housing need
*
Medical history
Mental health history
Mental health diagnosis, if any
Substance use history
*
Alcohol
Drugs
None
If you selected Alcohol or Drugs, please explain
Legal and Income Information
Are you currently on parole or probation?
*
No
Yes
Parole or probation officer name
Parole or probation officer phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you a registered sex offender?
*
No
Yes
Source of income
*
SSI
SSDI
Employment
Other
Monthly income amount
Housing Preferences and Accessibility Needs
Do you need any disability-related accommodations or supports?
*
Yes
No
If yes, please explain your accommodation or accessibility needs
Preferred room type
Please Select
Shared Room
Private Room
Independent Living Acknowledgment and Outside Support
Independent living acknowledgment
Can you live independently and manage daily activities without assistance?
*
Yes
No
If no, please explain what assistance is needed
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Agency or service name
Participant initials
*
Date
*
-
Month
-
Day
Year
Date
Program Agreement and Applicant Declaration
Acknowledgment of Program Expectations
*
I understand that if I am accepted, I must follow all house rules and program expectations, and participate in case management or program-related check-ins.
Acknowledgment of Rule Violations
*
I understand that violating house rules or program expectations may result in a warning, strike, or dismissal from the program.
Participant Name
*
First Name
Middle Name
Last Name
Participant Signature
*
Participant Date
*
-
Month
-
Day
Year
Date
Staff Name
*
First Name
Middle Name
Last Name
Staff Signature
*
Submit Application
Submit Application
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