Transitional Housing Intake Form
Welcome! Please fill out this form to help us process your application for transitional housing. This form is designed for individuals receiving Social Security, disability benefits, or other forms of government assistance.
Applicant Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Upload proof of ID
*
Upload a File
Drag and drop files here
Choose a file
proof of identification
Cancel
of
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Housing Information
Currently Homeless?
*
Yes
No
At Risk of Eviction
Other
Please describe your housing history and reason for seeking transitional housing
*
Wings of Hope Haven does not offer apartments or private houses. We provide private and shared rooms in a single family home. Do you understand you will be living in a house with other residents?
*
Yes
No
Have you ever lived in shared housing?
Yes
No
Base on your current income, what type of room do you want?
*
Shared Room starting at $750/mo
Private Room starting at $1000/mo
Any Available Option
How soon do you need to move in?
*
ASAP
Within a week
1-2 weeks
Next month
Other
How long do you need housing for?
*
Temporary: 1-3 months
Short Term: 3-6 months
Permanently: 6+ months
Other
If "other", please explain.
Financial Information
What type of government assistance do you receive?
*
Social Security (SS)
Disability Benefits (SSI/SSDI)
TANF
SNAP
Unemployment Benefits
Veterans Benefits
Other
If 'Other', please specify
Monthly Income from Government Assistance
*
When do you get paid?
Please upload proof of income (e.g., benefit statement)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Medical Information
Do you have any physical disabilities or mobility issues?
*
Yes
No
Do you have any medical conditions we should be aware of?
*
Physical Disability
Mental Health Condition
Chronic Illness
Substance Use Disorder
None
Please provide details of any medical conditions and current medications
*
Are you currently receiving treatment or therapy?
*
Yes
No
N/A
If yes, please describe.
Have you ever been hospitalized for mental health reasons?
*
Yes
No
If yes, please describe.
Referral Information
Name of Referring Agent
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Consent
If we are unable to provide housing, do you consent to Prosper Haven sharing your information with other independent living facilities that may have availability?
*
Yes
No
If accepted, I understand that my personal belongings may be searched when I move in or at any time while I am a member of Prosper Haven Housing. This includes bags, containers, and personal areas. Refusing a search may result in not being allowed to move in or being asked to leave the program
*
Yes
No
I understand that by submitting this application, Prosper Haven Housing may conduct a background check to verify the information provided. I also understand that if any information on my application is found to be false, incomplete, or misleading, Prosper Haven Housing reserves the right to deny my application or revoke housing approval at any time.
*
Yes
No
I certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that providing false information may affect my eligibility for transitional housing services.
*
Submit Application
Should be Empty: