Housing Intake & Pre-Screening Form

Housing Intake & Pre-Screening Form

Share your details to join the waiting list and complete the pre-screening.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Client Gender
Client Race
What are preferred communication type
Do We Have Permission to Send Text Message
Current Living Situation

Other
Preferred Housing Type
Do you require any accessibility features?

Other
Does Client Have Any Other Disability?(If Yes, Please Specify)
Does Client Have Mental Illness? (If Yes, Please Specify)
Is The Client a Sex Offender?
Is the Client on Parole or Probation?
Do you have a monthly income?
How Will Client Pay?

Other
Preferred Moving Day
How Did You Hear About Us
Please share any additional information or needs
Should be Empty: