Cherubim Grace Covering Intake Form
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
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
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:
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:
Have you ever been evicted from a previous residence?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, please in the box below
If you answered yes to the previous question, please explain below:
Are you a registered sex offender?
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: