Program Name
Date of Inquiry
Staff Member Completing Form
Full Name
Date of Birth
Phone Number
Email Address
Current Address or Location
City/State
Preferred Move-In Date
Gender MaleFemaleOther
Do you have children? YesNo
If yes, ages of children
Name
Relationship
Alternate Phone Number
What best describes your current situation?
HomelessLiving with Family/FriendsShelterHotel/MotelTransitional HousingFoster CareEviction PendingDomestic ViolenceSubstance RecoveryOther
How long have you been without stable housing?
Are you currently employed? YesNo
Employer Name
Monthly Income
Other Income Sources
SSISSDITANFSNAPUnemploymentChild SupportOther
Are you willing to participate in case management? YesNo
Attend life skills or wellness programs? YesNo
Follow house rules and curfew? YesNo
Participate in financial planning/budgeting? YesNo
Any mental health concerns requiring accommodation? YesNo
If yes, explain
Taking medications? YesNo
Struggling with substance use? YesNo
Require assistance with daily living? YesNo
History of violence? YesNo
Currently on probation or parole? YesNo
Preferred Housing Type Shared RoomPrivate RoomApartment
Estimated Length of Stay 30 Days60 Days90 Days6 MonthsOther
Do you have transportation? YesNo
Do you have pets? YesNo
If yes, describe
How did you hear about our program?
DHSWorkforce SolutionsShelterChurch/Faith-BasedSocial WorkerDoctorHospitalFriend/FamilyWebsiteOther
Referral Contact Name
Agency/Organization
Phone/Email
I understand this form is an inquiry/pre-screen form only and does not guarantee placement into the program.
Applicant Signature
Date
Approved for InterviewWaitlistDeclinedEmergency Placement Needed
Notes
Staff Signature
