Independent Supportive Housing Inquiry
Please Complete Entire Form.
Full Name
*
First Name
Last Name
DOB
*
example@example.com
Clients Gender*
Male
Femae
Transgender
Current Living Arrangement
*
Living with Family
Living on the street
Incarcerated
Shelter
Other
Have client lived in shared environment before?*
yes
no
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to text/leave a message on the number provided?
Yes
No
Race
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Representative Name:
Rep's Organization (ex: United Way, Va, etc )
What type of Room Does Client Prefer?
Shared Room
Private Room
When does client need to be Placed?
-
Month
-
Day
Year
Date
How will client pay?
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
How much income do you receive monthly? If none please type NONE*
Does the client suffer from mental illness?*
Yes
No
If answered yes, list mental diagnoses and are you medication complaint*
Are you disabled?*
Yes
No
List disability(s)*
Does client require a Handicap Accessible living environment?*
Yes
No
Is the client an ex-offender?*
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this questions does not disqualify you from our program & services)*
Yes
No
With 1000ft Restriction
Without 1000ft restriction
Are you currently on Probation or Parole?*
Yes
No
Are there any drug/alcohol abuse currently or in the past
Yes
No
If Yes how long have client been clean?
Tell us about Yourself?
How did you hear about us?
Referral
Social Media
Search Engine/Web
Submit
Should be Empty: