Faith First Independent Housing Pre-Screening / Intake Form
Please complete this pre-screening form to help match housing placement and support needs. Provide as much accurate information as possible; some fields are optional or conditional.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current Address
*
Referral Source
Agency
Case Manager
Hospital
Outreach Worker
Family/Friend
Self-Referral
Other
Referral Source - Other
Income & Benefits
Do you have a steady source of income?
*
Please Select
Yes
No
Primary Source of Income (check all that apply)
*
Employment
SSI
SSDI
Employment
Va Benefits
Retirement/Pension
Other
Estimated Monthly Income (income verification may be required prior to move-in)
Do you receive SNAP / EBT (Food Stamps?
Please Select
Yes
No
Do you have a working phone we can reliably contact you on?
*
Please Select
Yes
No
Independent Living Capacity
Can you live independently without daily assistance?
*
Please Select
Yes
No
Do you currently receive assistance with daily activities (cleaning, cooking, hygiene, or transportation?)
*
Please Select
Yes
No
If yes, please explain the assistance you receive.
Are you currently prescribed any medications?
*
Please Select
Yes
No
Do you experience difficulty accessing medications (cost, insurance, transportation etc, or other factors?)
*
Please Select
Yes
No
Sometimes
If yes, please describe the difficulty accessing medications.
Do you require reminders for medications or appointments?
*
Please Select
Yes
No
Do you have any mental health diagnoses the provider should be aware of? (Optional)
*
Please Select
Yes
No
If yes, please describe any mental health diagnoses the provider should be aware of.
Housing Preferences & Accessibility Needs
Preferred Room Type
*
Please Select
Private Room
Shared Room
Private Room with Bathroom
No preference
Preferred Move-In Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any physical disabilities or mobility limitations?
*
Please Select
Yes
No
If yes, please explain your accessibility needs
Do you require a ground-floor or downstairs room?
*
Please Select
Yes
No
Do you have reliable transportation?
*
Please Select
Yes
No
If not, do you need housing near a public bus route?
Please Select
Yes
No
Background & Legal History
Have you ever been evicted?
*
Please Select
Yes
No
Have you ever been convicted of a felony?
*
Please Select
Yes
No
Are you currently registered as a sex offender?
*
Please Select
Yes
No
Do you have any pending legal matters or court cases?
*
Please Select
Yes
No
If yes, please describe the pending legal matters or court cases.
Lifestyle & House Expectations
Are you willing to comply with house rules (no drugs, no unapproved guests, cleanliness standards, curfew/quiet hours, respect for others)?
*
Please Select
Yes
No
Do you smoke or vape?
*
Please Select
Yes
No
Do you consume alcohol?
*
Please Select
Yes
No
Do you have any pets?
*
Please Select
Yes
No
How would you describe your cleanliness level?
*
Please Select
Very Clean
Average
Needs Improvement
Do you have difficulty sharing space with others?
*
Please Select
Yes
No
Additional Information
Why are you seeking housing at this time?
*
Is there anything else you would like us to know to help with placement?
Emergency Contact (Optional but Recommended)
Emergency Contact Name
First Name
Middle Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Please Select
Parent
Sibling
Spouse/Partner
Friend
Case Manager
Other
Signature
*
Continue
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Should be Empty: