Emergency Housing Interest & Screening Form
Chances 4 Hope Housing – A Reentry Housing Program Sponsored by AC4C. Important Information: Weekly stay availability starting September 1, 2026; Double room occupancy; Community kitchen; Community dinners (Tues & Thurs, 7–8PM); Resource room hours (9AM–6PM); Quiet hours (10PM–7AM); Opening September 1, 2026! A Safe Place. A Fresh Start. A Brighter Future. Next Step: Free Screening – Our team will review your interest form and contact you to schedule a FREE screening prior to admission. Include Chances 4 Hope Hub House contact/location details as on flyer.
Applicant Information
Full 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
*
example@example.com
Current Situation and Housing Need
Current Living Situation
*
Homeless
Staying with friends/family
Shelter
Transitional housing
Recently released from incarceration
Other
If Other, please describe
When do you need housing?
*
Expected Length of Stay
*
Less than 1 week
1–4 weeks
1–3 months
More than 3 months
Payment and Support Status
Payment / Assistance Status
*
Self-pay
Housing voucher
Agency assistance
Other assistance
Not sure yet
Currently working with an agency or case manager?
*
Yes
No
Agency / Case Manager Name
Agency / Case Manager Phone or Email
Assistance Requested and Referral Source
Assistance You Are Seeking
*
Emergency housing
Reentry support
Case management support
Employment/resource connections
Other
Referral Source
*
Probation/Parole officer
Reentry program
Shelter or community agency
Friend/family
Social media/website
Other
Signature
Applicant Signature
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: