InTRANSition-Host Home Client Application
Thank you for contacting us! We want to help get you in contact with resources to help you relocate out of unsafe situations. Please fill out this application in it's entirety. Completion of this form does not guarantee housing, but we will use this information to find the most beneficial resources available. We will never sell, distribute, publish, or release any personally identifying information about our clients. Your application may take up to thirty days to process.
Email address *
Name *
Your answer
Pronouns *
Your answer
How do you self-identify
Street Address
Your answer
City *
Your answer
State *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Race
Phone Number *
Your answer
Is this your own, personal cell phone? *
What is your current living situation? *
Do you need help with immediate relocation? *
Your answer
Are you willing to or do you need to relocate for housing? *
Your answer
What is your employment status? *
Current Annual Income Level
What is Your Highest Level of Education?
Are you a US Citizen? (Not being a US Citizen does NOT disqualify you from receiving help, but helps us to ensure you have the most accurate help for your situation.)
Do you at least speak English fluently? *
If you answered no, which language is your primary language?
Your answer
Are you now, or have you ever been, suicidal? If so, have you made any serious attempts in the past? *
How long do you need housing? If more than a week, please explain why. *
Your answer
Do you have any prescribed medications you are currently taking? (Please include any hormones or hormone blockers you have a prescription for.) *
Your answer
Do you have any dependents that also need shelter?
If yes, how many?
Your answer
Do you have any pets? *
If you answered yes to the last question, how many and what kind(s)?
Your answer
Are they service animals?
Have you ever been convicted of a crime of any kind? If so, please explain. (Crime convictions DO NOT prevent you from receiving help from our program.) *
Your answer
Do you have a dependency on drugs or alcohol? If yes, please explain below. (This also does NOT exclude you from participating with our program) *
Your answer
Have you ever been hospitalized? If yes, please explain why. *
Your answer
Do you have your own form of transportation? *
Your answer
Do you have any members of your family that you are safe with? *
Your answer
Please list a minimum of 2 emergency contacts that we can speak with if necessary, with contact info. *
Your answer
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