First Name *

Last Name *

Gender *

Phone *

Email *

Housing Needed *

Permanent

Transitional

Emergency

Desired Move-In Date *

Do you have a Case Manager? *

Yes

No

Case Manager Name

Case Manager Organization

Case Manager Phone

Case Manager Email

Have you been in jail or prison within the last 5 years? *

Yes

No

Charge Description

Charge Year

Release Date

Diagnosed mental health condition(s)? *

Yes

No

List diagnoses

Can you take medications on your own? *

Yes

No

Sometimes

Health Notes *

How will rent be paid? *

SSI/SSD

Non‑profit assistance

Employment

Other

Rent Payment Other Details

Proof of Income *

Benefits card shown

Permission to verify with agency

Bank statements (last 3 months)

Other

Proof of Income Other Details

Have you lived in shared housing before? *

Yes

No

What worked/Didn’t work?

Reason for leaving

Any challenges we should plan for? *

Budgeting/finances

Gambling

Substance use

Other

Challenges Other Details

Anything else we should know to ensure a good fit? *

Applicant Consent *

I confirm the information above is accurate and authorize verification of housing and funding information for screening.

Applicant Signature

Clear

Signature Date

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