Full Name

Gender:

Gender:

Date of birth

Any physical limitations

Diagnosis

Medical diagnosis

HIV/AIDS

HIV/AIDS

Have you ever been to jail or prison?

Have you ever been to jail or prison?

Yes, please specify:

Do you have any charges, present or past?

Do you have any charges, present or past?

If yes, please list them

Are you currently on probation?

Are you currently on probation? If yes, why?

If yes, why?

Have you ever been on probation?

Have you ever been on probation?

If yes, why?

Are you a smoker?

Are you a smoker?

Have you ever used drugs?

Have you ever used drugs?

If yes please list them.

Are you on drugs now?

Are you on drugs now?

Do you drink?

Do you drink?

Do you smoke marijuana?

Do you smoke marijuana?

If yes, do you have a medical marijuana card?

What is the source of your income?

Do you have a representative payee or do you handle your own finances?

If you have a representative payee, we need to verify your income.

Do you have a caseworker?

Do you have a caseworker?

If yes, please list their name, number and the organization they represent.

Have you lived in a shared housing community before?

Have you lived in a shared housing community before?

Please list the last 3 places you have lived.

Please list 3 references if possible.