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First Name
*
Last Name
*
Email Address
*
Birthday
*
Month
Day
Year
Phone
*
What is your gender? (This helps me know which home you need to be placed in.)
*
Male
Female
Transgender
Representative Name
Representative's Organization (VA, United Way, etc)
What is your current living situation?
*
Living w/ a friend or family
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Shared Housing/Group Home
What type of room do you prefer?
*
Shared
Private
When do you need to be placed?
*
Message
*
How will you pay?
*
Job
SSI/SSDI
VA income
Retirement
Voucher
Organization Funding
Other
How much income do you receive monthly? (If none, please type NONE.)
*
Do you suffer from mental illness? (If yes, please list mental diagnoses.)
*
Are you disabled?
*
Yes
No
If you selected "Yes" for disabled, please list disabilities.
*
Do you require a Handicap Accessible living environment?
*
Yes
No
Are you an ex-offender?
*
Yes
No
Have you been convicted as a sex offender? (Your answer to this question does not disqualify you from our services and program.)
*
Yes
No
With 1000 ft restrictions
Without 1000 ft restrictions
Are you currently on Probation or Parole?
*
Yes
No
Are you seeking help with recovering from Opioids, Alcohol, and/or other drugs?
*
Yes
No
I'm already in a recovery program.
Will you have children living with you? (If so, please list the ages.)
*
Select all of the services you are requesting.
*
Transportation Assistance
Job placement
Apply for SNAP benefits
Apply for SSI/SSDI
Health Insurance Enrollment
Clothing Donation
Organizational Payee
Cellphone/Tablet Assistance
Group Therapy
Recovery Programs
How did you hear about us?
*
Referral
Search Engine/Web
Social Media
Other
Submit
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