Housing Intake form
Please complete this intake form to help us assess your eligibility and needs for our independent living housing program. This form is an initial screening. Final acceptance is based on availability and the interview process.
Who is completing this form?
Please Select
Case Worker/Social Worker
Self-Referral
Referring Agency
Family Member
Other
Full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Current housing situation
*
Please Select
Staying with family/friends
Shelter
Transitional housing
Homeless
Other
If Other please explain:
Monthly income (USD)
*
Preferred move-in timeframe
*
Please Select
Immediately
Within 30 days
Are you able to live independently?
*
Yes
No
Have you ever lived in shared housing before?
*
Yes
No
Medical/Behavioral or clinical needs (Internal use only)
This information will help determine the best housing placement and support needs
Ready to move in?
*
Yes
No
Acknowledgement
*
I confirm that the information provided is accurate and understand that submission does not guarantee placement
Submit
Should be Empty: