Housing Inquiry
Housing Intake Form
Email address *
Name *
Date *
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Phone *
Date of Birth *
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Do you have children in your care? *
For each child provide: Name, age, and Current School
Are you employed? *
If employed who is your employer?
How many hours/week do you work?
What is your hourly wage/ salary
Do you have your own transportation? *
Describe your current living situation: *
Are you seeking safety from someone? *
If you are seeking safety please explain:
Are you currently Pregnant? *
Do you have physical limitations that would make living in community difficult? *
If so please explain:
Have you recently experienced any mental health challenges? *
If so please explain:
Do you have any evictions or judgements on your record? *
If so please explain:
Once screened are you able to pass a background check? *
Please explain:
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