2023 Designed Future Housing Questionnaire
THIS QUESTIONNAIRE MUST BE COMPLETED IN ORDER TO BE CONSIDERED FOR HOUSING. Be detailed, factual and raw with your responses. Don’t add a lot of details. Just list the facts. Your answers will remain confidential.
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1.  Your First and Last Name: *
What is your date of birth *
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2.  Your Email Address: *
3.  Your Phone Number: *
4. Emergency Contact Information *
Please list the name and phone number of someone we can contact in the event of an emergency.
When is your scheduled move in date? *
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Have you been diagnosed with a mental illness? *
If you were diagnosed with a mental illness, what diagnosis were you given?
Have you ever had a traumatic brain injury? *
5.  Your Age: *
6.  Sex: *
7.  Race *
8.  Do you have children? *
How would you best describe your childcare situation?
Clear selection
What is your highest completed level of education?
Clear selection
9.  In what areas of life do you struggle? Which areas in life could use improvement? (CHECK ALL THAT APPLY.) *
Required
What are your current eating habits?
Clear selection
10.  Are you currently employed?   *
11.  If you're employed, what kind of job do you have? *
What is your current mode of transportation?
Clear selection
How would you describe the current state of your mental health and/or substance abuse?
Clear selection
12.  When was the last time you drank alcohol? *
Please provide the exact date.
13.  When was the last time you used drugs of any kind? *
Please provide the exact date.
14.  Income: *
Check All That Apply
Required
Are you experiencing any struggles when it comes to financial debt?
Clear selection
15.  What is your current housing situation? *
Have you experienced any emotional or physical abuse recently?
Clear selection
16.  Do you have a Michigan Bridge Card *
17.  Have you had interaction with any type of emergency services within the past year? *
Required
Are you currently dealing with any sort of legal complications?
Clear selection
18.  Were you previously in jail or prison in the last year?  If "Yes" please describe what you were charged with. *
Required
What crime were  you charged with?
19.  Do you currently have health insurance? *
Required
20.  What is your current health condition? *
Check All That Apply:
Required
21.  Please list any medications you are currently taking. *
22.  What is your height? *
23.  What is your current weight?   *
24.  Do you currently smoke cigarettes? *
Has anyone ever told you that you snore loudly? *
25.  If you currently smoke cigarettes, how many do you smoke on a daily basis?
26.  What are some of your current spiritual or religious beliefs? *
Would you say you feel a strong sense of purpose in your daily life?
Clear selection
28.  What is the status of your support system? These would include family and friends. (Check all that apply) *
Required
29.  Which of the following statements are accurate or true about yourself? (CHECK ALL THAT APPLY.) *
Required
Please indicate the emotions you have felt within the past 2-3 weeks: *
Check all that apply.
Required
Monthly rent at Designed Future is $600/month.
That's it! You're finished! Simply click the "Send Form" button, and we'll be in touch!
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