Gender
Please Select
Male
Female
Age
Please Select
0-18
18-34
35-54
55-74
over 74
What are your current sources of income?
Employment
SSI/SDI
Social Security
What is your current annual income?
Please Select
Less than $5,000
$5,000-$10,000
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
more than $40,000
Do you currently participate in a Section 8 Voucher Program?
Please Select
Yes
No
Is your voucher transferrable?
Please Select
Yes
No
Are you currently on a Section 8 Waiting List?
Please Select
Yes
No
If yes, how long have you been on the waiting list?
Do you participate in the RSVP (Rental Subsidy Voucher Program) through the San Diego Regional Center or any other type of housing allowance program?
Please Select
Yes
No
How much do you / can you currently pay for monthly rent?
Please Select
$0
$100
$200
$250
$300
$350
$400
More than $400
Where (City or Town) do you currently live?
Where would you like to live?
What type of residence do you currently live in?
Please Select
With Family
Studio or Single BR
Apartment or House w/ Roommate
Apartment or House w/ Caregiver
Group Home / Community Care
Other
If you selected other, please explain:
What kind of residence would you like to live in?
Please Select
With Family
Studio or Single BR
Apartment or House w/ Roommate
Apartment or House w/ Caregiver
Group Home / Community Care
Other
If you selected other, please explain:
Total # of people who will be living with you:
What kind of Developmental Disability do you have?
Autism
Epilepsy
Cerebral Palsy
Developmentally Delayed
Other (Vision, Hearing, Etc)
In addition to being a consumer of the Regional Center, have you been dually diagnosed Mental Health Services Act (MHSA) consumer?
Please Select
Yes
No
What would you need to live comfortably in your new home?
Wheelchair Accessibility
Roll-in Shower
Adaptations for Deaf or Blind
First Floor Unit
Single Story Unit
Companion Animal / Service Dog
Other
If you selected other, please explain:
** Please complete and return contact information below if you would like to be considered for housing opportunities as they present themselves in the future. Providing the Southern California Housing Collaborative with your information is voluntary and all of your information will be kept confidential. **
Name (Child and Parent)
Address
City, State, Zip Code
Phone
Cell Phone
Email
SDRC Case Worker's Name
SDRC Case Worker's Phone
Other Important Information
You will also need to be prepared to provide the following information:
Total number of people in your family looking for housing
All adults will need legal identification (Drivers License, State ID, Passport, Military, Visa or Birth Cert)
All minors must have a Birth Certificate
All tenants must have Social Security Numbers and Social Security Cards
Total Income for entire family (employment, disability, SSI, etc.)
Rental History for the past two years and proof that you have not been evicted for at least 5 years.
Depending on the property, you will not qualify if you have more than $10,000 to $20,000 in debt and cannot own more than 2 vehicles.
Depending on the property, you will be required to pay a security deposit between 300 and 600 dollars. (Your credit fee of $50 per adult may be waived)
Submit
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