One Person One Housed Intake

One Person One Housed Intake

Please complete the application section first. Once it has been submitted, a member of our staff will review your application and follow up.
Applicant Information
Date

MonthDayYear
Date
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Last 4 Digits of National ID
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How long have you lived there?
Primary Language
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referral and Housing History
How did you hear about the One Person One Housed Program?

Other
If Other, please specify (How did you hear?)
Referral Agency (if applicable)
Case Manager
Referral Agency Phone
Please enter a valid phone number.Format: (000) 000-0000.
Where did you sleep last night?

Other
If Other, please specify (Where did you sleep last night?)
How long have you been without stable housing?
What circumstances led to your housing crisis?
Have you ever experienced homelessness before?
If yes, when?
Housing Goals and Preferences
Current Employment Status
Employer
Position
Monthly Income (Employment)
Highest Level of Education

Other
If Other, please specify (Education)
Interested in employment assistance?
Income & Benefits (check all that apply)

Other
Total Monthly Income
Health and Support Needs
Do you currently receive mental health services?
Do you have any accessibility or mobility needs?
Support Services (check all you would like assistance with)

Other
Household and Safety
Are you currently fleeing domestic violence?
Do you currently feel safe?
Would you like to speak privately with an advocate?
Are you currently on probation or parole?
Do you have any pending legal matters that may affect housing?
If yes, please explain (legal matters)
References, and Document Uploads
Required Documents (check all provided)
Photo ID

Cancelof
Proof of Income

Cancelof
Benefit Letter

Cancelof
Applicant Signature
Applicant Signature Date

MonthDayYear
Date
Should be Empty:

One Person One Housed Intake

Applicant Information

Referral and Housing History

Housing Goals and Preferences

Health and Support Needs

Household and Safety

References, and Document Uploads