HEART: Application For Residence

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We unfortunately are unable to provide crisis housing at this time, if you are in crisis please call Crisis Intervention: (717) 394-2631 or 211

Please allow 48 hours for us to review your application and respond to you.

Email *

Full Legal Name *

Chosen/Actual Name (If different)

Form Completed By (If someone other than client)

Date of Birth *

Age *

Gender

Female

Male

Nonbinary

Genderfluid

Prefer not to say

Other:

Clear selection

Sexual orientation

Straight

Gay/Lesbian

Bisexual

Pansexual

Other:

Clear selection

Phone Number

Emergency Contact

Relationship to Emergency Contact

Current/Last Address (Including city, state, & ZIP)

Current Housing Situation

Homeless

Unsafe Housing

Doubled Up

Unstable

Couch Surfing

Shelter

Other:

Do you have mental health concerns? (Specify)

Clear form

Never submit passwords through Google Forms.

This form was created inside of Lancaster LGBTQ+ Coalition. Report Abuse

Forms