Housing Form
Please complete this form if you are in need of Shelter or Housing
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
What is your current address?
Your answer
Are you currently homeless, and looking for temporary housing?
If so, what is your current state, city, zipcode
Your answer
Will you be living by yourself?
if no, who will be living with you?
Your answer
Will children be living with you?
Do you have to register as a sex offender?
Are there housing restrictions according to your parole/probation guidelines? If, yes, what are they?
Your answer
Any past rental history?
Your answer
Do you have any evictions?
Preferred Location? If yes, where and why?
Your answer
Have you applied for any government housing benefits?
If yes, what?
Your answer
Are you currently employed?
Are you interested in obtaining a re-entry life coach?
If yes, please also complete the life coaching intake assessment on the life coaching page.
If you are in need of immediate assistance and support, call our 24hr resource/listening line! 1-844-9RE-ENTR
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service