Intake Form



Are You Married?(Required)


Do you have any current or past substance use?(Required)
Are you or have you ever been a survivor of domestic violence?(Required)
Are you currently fleeing a domestic violence situation?(Required)
Are you on probation or parole?(Required)
If you are currently homeless, have you been homeless for 12 or more months?(Required)
Have you been homeless off and on 4 or more times in the last 3 years?(Required)

Household Details

Are you the head of your household?(Required)
What is your current living situation?(Required)
How long have you been where you are currently living?(Required)

What barriers do you have for housing?

I am under the age of 25 and have no prior rental history.(Required)
I have a large gap in my rental history.(Required)
I owe a previous landlord money.(Required)
I have bad landlord references.(Required)
I am 16-27 and was under the jurisdiction of the juvenile court in the past 10 years.(Required)
Are you paying more than 1/3 of your monthly income towards rent/mortgage?(Required)
Are you currently being asked to leave your current residence and lack the resources to obtain other long-term housing?(Required)
Will you have Section 8 or rental assistance when you look for your new place?(Required)
Are you on any Housing Authority waitlist(s)?(Required)

Income – Please enter your income from the following sources: