New Customer Registration Form
Customer Details:
Name
*
First Name
Last Name
Phone Number
*
undefined
Format: (000) 000-0000.
E-mail
*
example@example.com
Gender
*
Male
Female
Representative's Name
*
First Name
Last Name
Representative's Organization (Ex. United Way, VA, etc.)
*
Do we have permission to text or leave a message for the phone number provided?
*
Yes
No
Race
*
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Pacific Islander
Date of Birth
*
-
Month
-
Day
Year
Date
Current Living situation:
*
Living w/a friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital / Facility
Shared Housing / Group Home
What type of room do you/the client prefer?
*
Shared
Private
When does you/the client need to be placed?
*
-
Month
-
Day
Year
Date
How will you/the client pay?
*
SSI / SSDI
Retirement
Voucher
Organizational Funding
Job
Other
How much income do you / the client receive monthly? If none, please type NONE
*
Do you / the client suffer from a mental illness?
*
Yes
No
If answered yes, please list the mental diagnosis.
*
Are you / the client disabled?
*
Yes
No
List the disability(ies):
*
Do you / the client require a Handicap Accessible living environment?
*
Type option 1
Type option 2
Type option 3
Type option 4
Are you / the client an ex-offender?
*
Yes
No
Have you been convicted as a sex offender? (Your answer to this question does not disqualify you from our program and services.)
*
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you / the client currently on probation or parole?
*
Yes
No
Do you need help recovering from Opioids and/or other drugs and alcohol?
*
Yes
No
Will you / the client have children that will be living with you? (Please list the ages)
*
How did you hear about us?
Referral
Search Engine / Internet
Social Media
Word of Mouth
Submit
Should be Empty: