Independent Housing Referral Intake Form
This intake form is for shared housing. The questions are designed to select the correct housing for your needs. Requirement: Income - must be able to afford $600 per month. No credit check is needed. Once the form is completed someone will contact you within 48 hours.
Clients Name
*
First Name
Last Name
What city and state are you looking for housing?
*
Gender:
*
Male
Female
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
example@example.com
Race:
Current Living Situation: (please explain)
What type of room does the client prefer?
*
Shared Room
Private Room
When does the client need to be placed?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
How much income does the client receive monthly? If none, please type NONE.
*
Does the client suffer from mental illness?
*
Yes
No
If yes, enter mental diagnosis.
Does the client currently or in the past had any substance abuse issues?
*
Yes
No
If yes, please explain briefly.
Is the client currently on probation or parole?
*
Yes
No
If yes, please explain briefly.
Is the client convicted of a felony?
*
Yes
No
If yes, please explain briefly.
Is the client disabled?
*
Yes
No
If yes, please explain briefly.
Does the client need the following services?
Apply for SSI/SSDI
Apply for SANP benefits
Apply for Veteran Benefits
How will the client pay?
*
SSI/SSDI
Retirement
Voucher
Organization Funding
Paycheck
Other
Representative or Caseworker Name, Email and Phone Number:
Representative's Organization (ex., VA, HUD, DHS, Wayne Metro, etc.)
Additional Notes:
How did you hear about us?
Please upload proof of income such as award letter from SSI/SSDI or pay stub:
*
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