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Housing Inquiry
Housing Intake Form
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Phone
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Do you have children in your care?
*
Yes
No
For each child provide: Name, age, and Current School
Your answer
Are you employed?
*
Yes
No
If employed who is your employer?
Your answer
How many hours/week do you work?
Your answer
What is your hourly wage/ salary
Your answer
Do you have your own transportation?
*
Yes
No
Describe your current living situation:
*
Your answer
Are you seeking safety from someone?
*
Yes
No
If you are seeking safety please explain:
Your answer
Are you currently Pregnant?
*
Yes
No
Do you have physical limitations that would make living in community difficult?
*
Yes
No
If so please explain:
Your answer
Have you recently experienced any mental health challenges?
*
Yes
No
If so please explain:
Your answer
Do you have any evictions or judgements on your record?
*
Yes
No
If so please explain:
Your answer
Once screened are you able to pass a background check?
*
Yes
No
Maybe
Please explain:
Your answer
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