This intake sheet is used to better understand your housing needs and how DRDz can assist. Our Housing Coaches will use this information to design a C.H.P-College Housing Plan that best fits your individual needs.
Full Name
*
First Name
Middle Name
Last Name
Age
*
Phone Number
*
Format: (000) 000-0000.
Race/Ethnicity
American Indian
Asian
Black
Caucasian
Hispanic/Latino
Pacific Island
Other:________
Zip code
*
Marital Status
Single
Married
Divorce
Separated
Widowed
E-mail
*
Do you have children?
*
Yes
No
Do you have a pet?
*
Yes
No
Are you employed?
*
Yes
No
What college do you or will you attend?
*
College Classification (Yr in College)
*
Entering Freshman
Freshman
Sophomore
Junior
Senior
Other(High School)
Major
Current living situation? where did you sleep last night
Renting a home
Renting a room
Living with family/friend
Own your home
Shelter
homeless
On campus housing
off campus student housing
Other
Have you been evicted in the last 12 months?
*
Yes
No
Describe your housing situation and why you feel you need assistance
*
What is your long term housing goal
*
TYPE OF HOUSING NEEDS:
Rental Assistance- behind in rental payment Amount past due?_______
Rapid Re-Housing- recently lost housing and finding a new place need assist with deposit and/or rent
Supportive Housing- case manager and additional services
Affordable Housing- need to find something you can afford
Section 8- income base Housing
Roommate match-looking for someone to share the rent
Private Student housing- off campus housing designed for college students
Companionship- light house cleaning and meals in exchange for free room and baord
Other
Please provide any additional information you would like to share.
Submit
Should be Empty: