top of page
intake-hero-filtered.png

JOIN NOW

Preliminary Housing Intake Form

A Place To Belong

Application Form

Take the first step toward finding stable housing and the support you need to move forward.

Client's Gender
Male
Female
Do we have permission to text/leave a message on the number provided?
Yes
No
Race
Caucasian
African American
Hispanic
Asian
American Indian/Native American
Islander
Client's Current Living Situation
Living w/a friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
How will the client pay?
SSI/SSDI
Retirement
Voucher
Organization Funding
Job
Other
Does the client suffer from mental illness?
Yes
No
Are you disabled?
Yes
No
Does client require a Handicap Accessible living environment?
Yes
No
Is the client an ex-offender?
Yes
No
Have you been convicted as a Sex Offender? (Your answer to this question does not disqualify you from our program & services)
Yes
No
With 1000ft restriction
Without 1000ft restriction
Are you currently on Probation or Parole?
Yes
No
Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?
Yes
No
Select all of the services you are requesting.
How did you hear about us
Referral
Search Engine/Web
Social Media
Word of Mouth
bottom of page