Application for Interview & Placement Consideration

Completion of this application does not guarantee housing placement.

Applications are used to determine eligibility for interview and shared housing consideration.

Qualified applicants will be contacted to schedule an interview.

First Name

Last Name

Date of birth

Phone *

Email *

Emergency Contact

Name
Relation
Phone Number

SECTION 2: HOUSING READINESS

Are you applying for yourself or on behalf of someone else?

For a client / individual support

For myself

Who will be living with you ? *

Just me

Me and 2 + Children

Me and 1 Child

Me , My Partner and Children

👉 If on behalf of someone else what is YOUR name / Organization / Agency (if applicable) or relationship to client:

Are you able to participate in an interview (in person or virtual) within the next week?

Yes

What type lodging are your seeking ?

SHARED - Room ($600+)

Private Room ($950+)

Are you able to move into shared housing by or around the 1st?

Yes

Possibility

SECTION 3: SHARED HOUSING UNDERSTANDING

Are you able to respect house rules, quiet hours, and shared space expectations?

Yes

Do you understand that this is a structured housing environment, not independent apartment living?

Yes

SECTION 4: INDEPENDENCE & SUPPORT

Are you able to independently manage daily living tasks (personal hygiene, medication reminders, basic routines)?

Yes

Do you currently receive case management or support services?

Yes

Option 3

If yes: Agency / Provider Name - Case Manager Name & Contact (if available)

SECTION 5: FINANCIAL & PROGRAM FIT

Will housing costs be

Self - pay

Agency - assisted

Program - funded

Combination

Are you able to discuss housing fees and expectations during the interview process?

Yes

SECTION 6: INTERVIEW CONSIDERATION

Do you have a case manager , social worker or parole officer ? if so list name and contact info here .

SECTION 7: ACKNOWLEDGMENT

I agree to receive SMS messages from Serenity Bridges Housing Solutions regarding housing inquiries, appointment reminders, and application updates. Message frequency varies. Message & data rates may apply. Reply STOP to opt out or HELP for assistance.

I give permission for Emergency Contact listed above to be contacted in the event of an emergency, welfare concern, rule violation, medical situation, or if communication with me cannot be established. I confirm that the information provided is accurate and up to date.

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