Housing Application
Referral Information
Referral Source:
Contact Person:
Phone:
Format: (000) 000-0000.
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Applicant Information
Applicant Name:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Address:
City/State/ZIP:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender:
Pronouns:
Preferred Move-In Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physically Independent?
Yes
No
Emergency Contacts
Name:
Relationship:
Phone:
Format: (000) 000-0000.
Address:
Back
Next
Emergency Contact 2
Name:
First Name
Last Name
Relationship:
Phone:
Format: (000) 000-0000.
Address:
Behavioral & Background
History of suicide attempts/ideations?
Yes
No
Explain:
History of violent behavior?
Yes
No
Explain:
History of malicious behavior?
Yes
No
Explain:
Registered Sex Offender?
Yes
No
Explain:
Felony Convictions?
Yes
No
Explain:
Substance Use
History of alcohol/drug use:
Date of Last Use:
Previous Treatment Programs:
Longest Period of Drug Abstinence:
Health Information
Check all that apply:
Diabetes
Heart Disease
Kidney Disease
Dialysis
Thyroid
Respiratory
Vision
Hearing
Seizure Disorder
Other
Medical Conditions / Explanation:
Current Medications:
Allergies:
Income & Resources
Income Source (SSI/SSDI/VA/Employment/Other):
Monthly Income:
Back
Next
Employment Plans:
Payment Method:
Medicaid
Yes
No
Medicare
Yes
No
VA Benefits
Yes
No
Lifestyle
Smoker?
Yes
No
Housekeeping Style:
Neat
Casual
Disorganized
Lifestyle:
Social
Homebody
Previous Eviction?
Yes
No
Explain:
Applicant Certification
I certify that the information provided is true and complete to the best of my knowledge. I understand submission of this application does not guarantee housing placement. A non-refundable $150 processing fee is due prior to or on the day of move-in if approved.
Applicant Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: