Housing Intake Form for The Rock and The Revival
Please provide your contact details and housing needs to get started.
Contact & Basic Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Current City or General Location
*
How Are You Reaching Out?
*
Self-referral
Referred by an agency/case manager
Referring Agency Name
Case Manager Name
Case Manager Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
How did you hear about us?
Please Select
Word of mouth
Church
MDHHS
2-1-1
Social media
Other
Housing Eligibility Pre-Screen
Are you 18 years of age or older?
*
Yes
No
Gender
*
Male
Other
Current Housing Situation
*
Unsheltered (living outside, in a car, etc.)
Emergency shelter
Doubled up / staying with others
Transitional housing
Other
Are you a veteran?
*
Yes
No
Briefly describe your current housing need
*
Program Interest
Which services are you interested in?
Shared/subsidized housing
Workforce development & job placement
Vocational training
AI & technology education
Entrepreneurship support
Financial literacy
Availability & Timeline
How soon do you need housing?
*
Immediately
Within 2 weeks
Within a month
Just exploring options
Consent & Privacy
I consent to be contacted by The Rock and The Revival, Inc. regarding my inquiry.
*
I consent to be contacted by The Rock and The Revival, Inc. regarding my inquiry.
View our Privacy Policy
. Your information will be used and stored in accordance with our privacy practices.
A full intake interview and Consent for Release of Information will be completed in person before move-in.
Submit Intake
Should be Empty: