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First name
*
Last name
*
Birthday
*
Month
Day
Year
Email ( If available)
Phone
Where were your Referred from? (Agency, case manager, family member, other.)
*
Income & Benefits
Do you have a steady source of income?
*
Yes
No
What is your main source of income?
*
Employment
SSI
SSDI
VA Benefits
other
Do you receive Food Stamps/ EBT (SNAP Benefits)?
Yes
No
Independent Living Ability
Are you able to live independently without daily assistance?
*
Yes
No
Do you currently receive help with daily tasks (cleaning, cooking, hygiene, etc)
*
Yes
No
If yes, please explain
Are you currently taking any prescribed medication?
*
Yes
No
Do you have any difficulty accessing you medications (cost, transportation, insurance, etc.)?
*
Yes
No
If yes, please explain
Housing Preference & Needs
What type of room are looking for?
Shared Room
Private Room
Private Room with Bathroom
No Preference
When do you need housing?
*
Do you have any physical disabilities or mobility concerns?
*
Yes
No
If yes, please explain
Background Information
Have you ever been evicted form a previous residence?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Lifestyle & House Rules
Are you willing to follow house rules? ( e.g., no drugs, no unapproved guests, quiet hours, etc.)
*
Yes
No
Do you smoke?
*
Yes
No
Do you have any pets
*
Yes
No
Is there anything else you'd like use to know?
Submit
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