Section 1: Referrer Information (if different from applicant)

Referring Organization or Church Name

Your Name

Your Email Address

Your Phone Number

Section 2: Applicant Information

Applicant Full Name *

Applicant Phone Number *

Date of Birth or Age *

Applicant Email

Preferred Method of Contact *

Phone

Text

Gender *

Male

Female

Transgender

Does the applicant currently smoke (cigarettes, cigars, or vapes)?

Yes

Occasionally

Prefer not to say

Note: This helps us match applicants with homes that fit their lifestyle. Smoking indoors is not allowed in any of our properties.

Section 3: Housing Readiness & Eligibility

If the applicant is currently homeless, how long have they been without stable housing? *This helps us understand their situation and urgency. All information is confidential.

When does the applicant need housing?

Is the applicant able to live independently (without daily assistance) *

Yes

Unsure

Does the applicant require supervision or help with daily tasks? *

Yes

Unsure

Is the applicant able to manage medications independently? *

Yes

Unsure

N/A

Is the applicant currently taking any medications?

Yes

Unsure

N/A

If yes, please list any medications you feel comfortable sharing: This helps us ensure our housing is a good fit. We do not provide medical care or manage medications.

Any history of violence, property damage, or disruptive behavior? *

Yes

Unknown

If yes, please explain briefly:

Has the applicant been convicted as a Sex Offender? *

Yes With 1000 ft restriction

Yes Without 1000 ft restriction

Unsure

Your answer to this questions does not disqualify you from our program & services

Confirm income-Please upload proof of income *

Section 4: Preference

Private or shared room?

Private

Private with bath

Shared

No preference

Anything else we should know about this applicant?

How did you hear about us? *

Referral

Search Engine/Web

Social Media

All information submitted is kept confidential and used solely for intake purposes by Steady Steps Living.

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