Housing Program Questionnaire
Thank you for your interest in ReNew Housing Solutions. This application is the first step toward being considered for our affordable, all-inclusive shared housing program. Completing this form helps us learn more about your housing needs and determine eligibility.Please note: Submitting an application does not guarantee placement. All applications are reviewed carefully, and housing is offered based on eligibility, availability, and compliance with program guidelines.
Referral Information
How did you hear about us?
Are you working with or under any housing or management companies? If yes, who?
Personal Info
Full Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Phone Number
*
Enter a valid phone number for communication.
Date of Birth
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Day
-
Month
Year
Email Address
Enter a valid email address for communication.
What is your current living situation?
*
Anticipated Move In Date:
Emergency Contact:
*
Income
What is your source of income?
*
What is your monthly income?
*
Mental Health & Wellness
Do you have any current medical conditions? If yes, do you have a treatment plan in place? Please explain:
*
Have you ever been diagnosed with a mental health condition? If yes, do you have a treatment or medication plan in place? Please explain:
*
Do you have accessibility needs? Please explain:
Substance Use History
Have you struggled with substance use in the past? Please explain:
*
Are you currently sober? If yes, how long?
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Background Information
Do you have a criminal history? If yes, please explain:
*
Are you currently facing any legal charges pending? If yes, please explain:
*
Have you ever been convicted of a violent or sexual offense? If yes, please explain:
*
Are you currently on supervision? If yes, please explain:
*
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Submission
Signature
*
Submit
Submit
Should be Empty: