Young Adult Interest Form
If you are 18-24 years old and are in need of supports and housing, please fill out the below information and someone will be in touch with you shortly.
Email address *
Name *
Pronouns *
Required
Age *
Phone number to contact you *
How did you hear about our program?
Have you ever been homeless or in need of housing support before? If so, when was that?
Where would you like to be long term, as in Durham, Chapel Hill, Raleigh, or elsewhere?
Are you looking for short or long term support from a program?
What are your transportation options? Do you have a car, use the bus, etc.? 
Are you currently, or have you recently, been enrolled in any school programs OR are you still in high school? If so, what school(s)?
Are you currently working and/or have any savings? If you are working, generally, what is your availability to meet outside of your work schedule?
Are you currently working with other service providers, and if so, which ones and what are the specific names of case managers or other contact folks?
What are a few goals you have for the next 6 months, the next year, and the next 3 years? In other words, what would you want us to support you in achieving in the near future?
Submit
Never submit passwords through Google Forms.
This form was created inside of The LGBTQ Center of Durham, Inc. Report Abuse