Shared Maternity Housing Application

Shared Housing Application

Application for shared housing for pregnant women and young mothers. Use the field labels and order from the reference PDF. This is a standard online form, not a Smart PDF.
Application Information
Were you referred to our program?
If Yes, by whom?
Please confirm the name of the individual or organization
Full Name
How old are you?
Date of birth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Which Casa Atabey Program Are You Applying For?
Are you currently pregnant?

What services or support would be helpful to you during your participation in Casa Atabey?

Rows	No Support Needed	Information/Resources	Referral Assistance	Ongoing Support Needed
Housing Stability & Permanent Housing
Employment & Workforce Development
Education / Vocational Training
Financial Literacy & Budgeting
Transportation
Food / Nutrition Assistance
Health Care / Insurance
Mental Health / Wellness
Substance Use / Recovery Support
Benefits Assistance (SNAP, AHCCCS, DES, WIC, etc.)
Parenting / Family Support
Childcare Resources
Children's Services / Educational Support
Legal / Advocacy Resources
Life Skills / Independent Living
Identification / Vital Documents
Community Resources / Case Management

Please tell us more about the services or support you selected above: Include any immediate needs, current services, agencies you are already working with, or specific assistance you would like Casa Atabey to help you locate.

What treatment and/or services are you currently receiving or are pending:

Rows	Enrolled	Pending Enrollment	Not Enrolled	Need Enrollment
Behavioral Health / Counseling
Psychiatric Services
Medication Management
Substance Use Treatment
Recovery / Peer Support
Primary Medical Care
Pregnancy / Prenatal Care
Case Management
Care Coordination
Probation / Parole / Reentry Services
Domestic Violence / Victim Services
Employment / Workforce Services
Vocational Rehabilitation
DES / Benefits Services
Child / Family Services
Other Community Support Services
Services are pending / waiting for enrollment

Minor Children Details

Please fill out for each child who will be residing with you in the home.
Child 1: Full name:
Date of birth:
Age:
Relationship:
Child's gender:
Current school enrollment status:
Custody arrangement:
Are any court orders affecting the child's residence:
If so, please provide details
Has your child been diagnosed with a mental health, developmental, behavioral, or physical health condition that may require additional support or accommodations while residing at Casa Atabey?
Please briefly describe any accommodations or support your child may need while residing in the home while residing at Casa Atabey?
This information helps Casa Atabey understand whether your child may need additional accommodations, resources, or community-based support while residing in the program. A diagnosis does not automatically affect eligibility.
Child 2: Full name: (If Applicable)
Date of birth: (If Applicable)
Age: (If Applicable)
Relationship: (If Applicable)
Child's Gender: (If Applicable)
Current school enrollment status: (If Applicable)
Custody Arrangement: (If Applicable)
Are any court orders affecting the child's residence: (If Applicable)
If so, please provide details
Has your child been diagnosed with a mental health, developmental, behavioral, or physical health condition that may require additional support or accommodations while residing at Casa Atabey (If Applicable)?
Please briefly describe any accommodations or support your child may need while residing in the home while residing at Casa Atabey? (If Applicable)
This information helps Casa Atabey understand whether your child may need additional accommodations, resources, or community-based support while residing in the program. A diagnosis does not automatically affect eligibility.
Housing and Personal Details
What is your current living situation?
Describe the reason for seeking housing; whether they are homeless/at risk of homelessness; current housing deadline; desired move-in date; whether they can move immediately; expected length of stay; and what they hope to accomplish while living at Casa Atabey.
Have you been in programing in the past?
Are you currently transitioning from a treatment program, sober living program, shelter, domestic violence program, correctional/reentry program, hospital, behavioral health program, or another supportive setting? If so, please confirm the former program.
Are you currently employed or pending employment (start date confirmed)? If so, who is your employer?
Please provide the following information: employer; employer phone; position; start date; hours per week; pay frequency; approximate monthly gross income; other income; benefits; and ability to provide proof of income/employment.
Are you currently attending school or a training program? if so, who is your where?
Are you able to consistently pay the applicable Casa Atabey monthly program fee?
Shared Housing Fit and Background
All adult applicants are required to successfully complete a background screening before admission. Do you agree to this background check?
Have ever been convicted of a criminal offense, or have any of the following: pending criminal charges, current probation/parole, and outstanding warrants?
Disclosure DOES NOT automatically disqualify someone from the program. However, exclusions do apply in order to ensure safety of all participants and staff within the program.
Do any of the following offenses apply to you?
Are you open to rooming with another mother or single woman?
Are you looking for a private, shared suite or home?
What is your primary means of transportation"
Intake Readiness and Accessibility
What is the best method and time to contact you for intake once a private room becomes available?
Please acknowledge that you have read and understand the urgency of completing the intake form within 48 hours.
How soon are you looking to transition into one of our homes? Please provide a date.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Shared Housing Application

Application Information

Minor Children Details

Housing and Personal Details

Shared Housing Fit and Background

Intake Readiness and Accessibility