Cusdom Enterprises Housing Application

Cusdom Enterprises Pre-Screening Client Intake Form

Please complete the required fields with accurate information for review.
Applicant Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referral Source
How did you hear about Cusdom Enterprises?
Are you completing this application for yourself or on behalf of someone else?
If on behalf of someone else, what is your relationship to the individual?
Referral Contact Email
example@example.com
Can Cusdom Enterprises contact the referral source about your housing need?
Housing Need & Urgency
What is your current housing situation?
How soon do you need housing
Please briefly describe your main reason(s) for seeking housing at this time?
Payment / Funding Source
How do you plan to pay for housing?
If you have a case manager or funding coordinator, please provide their name and contact information.
What is your approximate monthly income?
Do you have the ability to pay a monthly rent or program fee?
Shared-Living Fit & Conduct
Are you interested in shared room, private room, or either
Have you lived with roommates or in a group setting before?
What is your comfort level with sharing common spaces (kitchen, living room, etc.)?
Do you have any preferences or needs regarding roommates (e.g., gender, age, quiet hours, etc.)?
Are you able to follow shared living guidelines (such as noise, cleanliness, and respect for others)?
Independent Living Ability
Are you able to independently manage daily self-care (such as bathing, dressing, taking medications as needed, etc.)?
Are you able to prepare simple meals for yourself?
Are you able to follow shared living guidelines and keep your living space clean (such as noise, cleanliness, and respect for others)?
Are you able to manage your own schedule (appointments, daily routines, etc.)?
Can you use public transportation or arrange your own rides?
Safety & Background
Is there anything that might impact your ability to live safely with others?
Have you ever been asked to leave a housing program or group living situation?
If yes, you may share more if you wish (optional):
Do you have any current legal restrictions that would affect your housing eligibility (for example, court-ordered restrictions on where you can live)?
Support & Accommodation
Do you have any support needs or reasonable accommodation requests (such as mobility aids, visual alarms, service animal, etc.)?
Are there any supports or accommodations that would help you live more independently?
Daily Practical Information
Do you have any dietary needs or food allergies?
Do you smoke or vape?
Do you have pets or service animals?
If yes, please describe the type of animal.
Do you need any reasonable accommodation to safely participate in shared housing?
If yes, please describe the accommodation requested.
Are you currently receiving Medicaid Waiver services?
If yes, which waiver?
Please provide waiver provider / agency name & contact.
Do you have a case manager or support worker?
Do you have a representative payee?
If yes, please provide payee name & contact information.
Do you have any criminal convictions?
If yes, please briefly describe the nature and date.
Are you currently on probation or parole?
If yes, please provide probation/parole officer name & contact.
Is there any current conflict, safety concern, or restraining order situation we should be aware of for placement safety?
If yes, please share what Cusdom Enterprises should know for safety planning.
If considered for this housing program, are you able to provide required income verification? (Select all that apply)
Who will be responsible for payment?
Name of agency, program, or person responsible for payment, if applicable.
Payment contact name (first & last name), phone, and email.
Is funding already approved?
If funding is approved, what amount is approved?
Communication Consent
Do you consent to be contacted by Cusdom Enterprises regarding your intake form?
What is your preferred method of communication?
Please feel free share any additional details you would like for us to know before submitting this intake form.
Applicant Acknowledgement
By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this intake form does not guarantee placement in Cusdom Enterprises' independent living program.
Applicant Signature
Date

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

Cusdom Enterprises Pre-Screening Client Intake Form

Applicant Information

Referral Source

Housing Need & Urgency

Payment / Funding Source

Shared-Living Fit & Conduct

Independent Living Ability

Safety & Background

Support & Accommodation

Daily Practical Information

Communication Consent

Applicant Acknowledgement

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this intake form does not guarantee placement in Cusdom Enterprises' independent living program.