PLCE Applicant Intake Form

PLCE Applicant Intake Form

Please complete this intake form to help us assess your eligibility and needs.
Applicant Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Living Situation
Current or Previous Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you currently under supervision of parole, probation, or alike?
Are you a sex offender?
Marital Status
Will you require housing for your partner/spouse as well?
Total Household Monthly Gross Income (before taxes/deductions)
How many appointments do you have per month?
Will you need transportation?
Are you or your spouse currently receiving government benefits (ex., SSI, Social Security, Veterans Benefits)
Do you currently own a home or real estate property?
Do you or your spouse smoke?
Are you agreeing to shared living?
Are you interested in a single (private) suite (additional costs apply)?
Will you require supportive services such housekeeping, daily living assistance, meal delivery, transportation to appointments, or alike?
Are you currently using mobility aids (e.g., wheelchair, walker, cane)?
Do you have or will you require any of the following? (Select all that apply)
List any chronic medical conditions (ex. Diabetes, COPD, Heart Disease, Dementia, Parkinson's, Multiple Sclerosis, etc.)
Primary reason(s) for seeking new housing

Other
If other selected, please explain
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is there anything else you would like us to know?
Should be Empty: