Time 4 A Change Housing Program Application

Time 4 A Change Housing Program Application

Complete this application with your personal, referral, housing, and program agreement details.
Applicant Information
Today’s Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Driver’s License or State ID Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Permission to email, text, or leave voicemail at the provided number
Gender

Other
Referral Information
This application is being completed by

Other
Case Manager Name

First NameLast Name
Organization Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Source (if applicable)
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
Current Situation
Are you looking for family housing for you and your children?
Current Living Situation

Other
Preferred Move-In Date

MonthDayYear
Date
Desired Housing Location
Health & Background
Medical history (type N/A if none)
History of any mental health conditions?
If yes, please explain; if no, type N/A
Veteran?
Substance use history, if any
If yes, please explain; if none, type N/A
Willing and able to comply with living in a drug- and alcohol-free environment?
Smoker?
Currently on parole or probation?
Any pending charges?
Financial Information
Source of income?
Frequency of payment
How will the monthly program fee be funded?

Other
Proof of income?
Monthly income amount ($)
Housing Needs & Preferences
Do you have a pet, service animal, or emotional support animal (ESA)?

Other
Do you have any allergies or disabilities that would need to be accommodated?
If so please explain
Mobility Needs
Preferred Room Type
Can you live independently and manage your daily activities without assistance?
Do you currently have or need a home health care provider or outside support service?
If we are not able to place you in our homes, are you ok with us referring you to one of our referral partners?
Program Agreements
I understand that this is housing only and I am responsible for my own personal care, medical needs, and daily living tasks
I agree to follow all house rules and expectations and participate in case management or program check-ins
Are you comfortable living in a shared household and participating in house chores?
Are you willing to live in a strict drug- and alcohol-free environment?
I acknowledge that violating house rules may result in a strike or dismissal from the program
I certify that the information provided is true, understand that this application does not guarantee placement, and acknowledge that staff will review it
Signature
Name

First NameLast Name
Signature
Should be Empty:

Time 4 A Change Housing Program Application

Applicant Information

Referral Information

Emergency Contact

Current Situation

Health & Background

Financial Information

Housing Needs & Preferences

Program Agreements

Signature