Client Application Form

Intake Form

Affordable Housing Program
We are excited about the opportunity to extend help in your time of need. The intake form is for the wait list and admission is based on bed and room availability. It does not guarantee a secured room.
Full Name*

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
example@example.com
Are we allowed to leave a voicemail or send a text message to the number provided?

YesNo
Date of Birth *

MonthDayYear
What is your gender?*

MaleFemale
If female, are you currently pregnant?*

YesNoNot Applicable
Who are you applying for?*

MyselfA Client (Social Worker, Case Manager, Agency, etc.)Family MemberOther
If applying for yourself, do you have case manager or support worker?

YesNo
What is your current living situation?*

Living with a friend/family memberLiving in a carLiving in a shelterLiving on the streetLiving in addiction recovery housingOther
Why are you seeking housing at this time?*
Please let us know how long you are in need of housing*

30 days or less2-4 months5-7 months8+ months
Requested Move-in date?*

MonthDayYear
What type of room are you looking for?*

Shared RoomPrivate RoomPrivate Room with BathroomNo Preference
Are you comfortable living in a shared housing environment with other adults?*

YesNo
Have you ever been evicted from a previous residence?*

YesNo
Are you a registered sex offender?*

YesNo
Do you have a felony or misdemeanor?*

YesNo
If yes, please explain details below.*
Do you have transportation?*

I have my own vehicleI have a dependable person for transportationI ride the busI use uber or a transport pick-up serviceI do not have reliable transportation
What is your main source of income?*

SSISSDIEmploymentAgency Funding/ProgramVA BenefitsOther
What is your estimated monthly income?*
Upload proof of income below *

Cancelof
Do you receive Food Stamps / EBT (SNAP Benefits) ?*

YesNo
Do you have any pets or a service animal?*

YesNo
Are you currently taking any prescribed medications?*

YesNo
Are you a smoker?*

YesNo
Do you drink alcohol or take any substances?*

YesNo
Do you have any physical disabilities or mobility concerns?*

YesNo
Do you have any other health issues we should be aware of?*
Are you willing to follow house rules (e.g., no drugs, no unapproved guests, quiet hours, cleanliness)?*

YesNo
Are you able to live independently without daily assistance?*

YesNo
Do you currently receive help with daily activities (cleaning, cooking, hygiene, etc.)?*

YesNo
If yes, please explain
How did you hear about us?
If you are representing an organization and filling this form out on behalf of a potential client, please leave your contact information below
Signature: By entering your name below you are verifying that all information provided is accurate and true to the best of your knowledge.*

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Intake Form

We are excited about the opportunity to extend help in your time of need. The intake form is for the wait list and admission is based on bed and room availability. It does not guarantee a secured room.