Cherubim Grace Covering Pre-Screening Intake Form
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact Name
*
Emergency Contact's Phone Number
*
Relationship to Emergency Contact
*
Where were you referred from? (Agency, Case manager, family member, self, etc.)
*
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
SSI
SSDI
Employment
VA Benefits
Other
What is your estimated monthly income? (We may ask for confirmation proof that it can be shown in person or sent electronically.)
*
Do you receive Food Stamps/EBT (SNAP benefits)?
*
Yes
No
Do you have a working phone we can use to contact you?
*
Yes
No
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)
*
Yes
No
If yes, please explain below
If you answered yes to the previous question, please explain below:
*
Are you currently taking any prescribed medications?
*
Yes
No
Do you have any difficulty accessing your medications (cost, transportation, insurance, etc.)?
*
Yes
No
If yes, please explain below
If you answered yes to the previous question, please explain below. (If not type N/A).
*
What type of room are you looking for?
*
Shared Room
Private Room
Private Room with Bathroom
No Preference
When do you need housing? (Move-in date):
*
Do you have any physical disabilities or mobility concerns?
*
Yes
No
If yes, please explain in the box below
If you answered yes to the previous question, please explain below. (If not type N/A).
*
Have you ever been evicted from a previous residence?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain in the box below
If you answered yes to the previous question, please explain below:
*
Are you a registered sex offender?
*
Yes
No
If yes, please explain any register requirements and any restrictions below
If you answered yes to the previous question, please explain below:
*
Do you have any Pending charges?
*
Yes
No
If you answered yes to the previous question, please explain below
*
Are you willing to follow house rules (e.g., no drugs or alcohol, no unapproved guests, quiet hours, cleanliness)?
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets?
*
Yes
No
Why are you seeking housing at this time?:
*
Is there anything else you would like us to know?:
*
Submit
Should be Empty: