Pre-Screening Application

Pre-Screening Application

Please complete this application to help us determine your eligibility.
Full Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Source of Income
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you ever been convicted of a felony?
Do you currently have any pending criminal charges?
If yes, please provide details about the conviction or charges.
Are you currently receiving mental health treatment or support?
Are you currently under supervision?
If yes, please share any details you'd like us to know.
Are you willing to share a room?
Preferred Roommate Preferences
Who referred you? (caseworker/agency name)
Do you have a valid ID?
Have you ever been convicted of a violent or sexual offense?
Are you currently facing any pending legal charges?
If yes, please explain.
When are you looking to move in?

MonthDayYear
Date
Have you struggled with substance abuse in the past?
Should be Empty: