Email

How did you hear about us?

How soon do you need housing?

Do you currently have a solidified income source? If so, (Who?, When is your next pay date?, How much?)

SSI, SSDI, Employment, or Private Pay

Are you able to independently travel up and down stairs?

Do you have children or dependants living with you?

If yes, list ages below.

When was the last time you used drugs or alcohol (if any)?

Are you currently in recovery or a treatment program?

If yes, where and how long?

Do you attend NA, AA, or recovery meetings?

If yes, how often?

Have you had any recent relapses?

If yes, when and what lead to it?

Are you currently prescribed any medications for mental health or recovery?

If yes, please list below.

Do you have a mental health diagnosis or condition you are managing?

If yes, please list below (Depression, Anxiety, PTSD, Bipolar, Schizophrenia).

Have you been arrested or incarcerated within the last 12 months?

If yes, explain below.

Are you currently on probation or parole?

If yes, explain below.

Are there any open warrants or pending court cases?

If yes, explain below.

Have you ever been charged with or convicted of a violent crime?

If yes, explain below.

Have you ever been asked to leave a shelter, program, or residence for behavioral issues?

If yes, explain below.

Do you have any restraining orders or conflict with other residents/staff in prior programs?

If yes, explain below.

Do you have any gang involvement or unsafe associations that may affect your safety?

If yes, explain below.

How do you typically handle stress, conflict or disagreements?

Talk it out, Avoid Conflict, Get Angry, or Walk Away

Do you currently have any personal protection or weapons?

If yes, explain below.

Do you have any health conditions that could affect your daily living?

If yes, explain below.

Are you able to manage your medications on your own?

If no, please explain below.

Do you have any mobility limitations?

Walker, wheelchair, cane, etc.

Do you require help with bathing, dressing or daily activities?

If yes, please explain below.

Have you been hospitalized (medical or psychiatric) in the last 6 months?

If yes, please explain below.

Do you currently receive in-home care or case management?

If yes, who provides it.

Are you currently connected with a doctor, therapist, or clinic?

If yes, who. and where?

Are you allergic to anything (food, medication, etc.)?

If yes, please explain below.

Need Housing?

Contact Us