Housing Application Eng

"*" indicates required fields

Housing Screening

Name*

First Middle Last

Email*

Phone*

Birth Date*

Your Age*

Please enter a number from 16 to 100.

Gender*

Male

Female

Are you pregnant?*

Yes

When are you due?*

Are you receiving prenatal care?*

Yes

What languages do you speak?*

English

Spanish

French

Other

Race*

African American

Asian

Caucasian/White

Hispanic

Native American

Other

Marital Status*

Single

Married (check only if your spouse needs housing too)

Divorced/Separated

Other

Do you receive food stamps or Medicaid?*

Yes

What county are your food stamps or Medicaid registered?*

I have a Drivers License.*

Yes

What state is listed on your Drivers License?*

I have a government issued ID.*

Yes

What state is listed on your government issued ID?*

Are you currently homeless?*

Yes

Where do you currently live?*

With friends or family

Shelter, hotel, or car

In a rented apartment

In a home that I own

Other

Current Address*

Street Address Address Line 2 City State ZIP Code

If staying in a rented apartment or home that you own

Please specify the last address where YOU rented or owned a home or apartment (in any city or state)*

Street Address Address Line 2 City State ZIP Code

If currently staying with friends or family

I currently live in Cabarrus or Rowan County*

Yes

Please list the last address where YOU rented or owned a home or apartment (in any city or state)*

Street Address Address Line 2 City State ZIP Code

If currently residing in Cabarrus or Rowan County

Please list the address at which you are currently staying (outside of Cabarrus or Rowan County)*

Street Address Address Line 2 City State ZIP Code

If currently residing outside of Cabarrus or Rowan counties

Why do you need housing?*

My rent increased and I can no longer afford it

I have an eviction on my record

Relationship ended

I can no longer live with family/friends

My income is too low

Other

Please select all that apply.

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Please select the city you reside in.

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Last known address*

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City*

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County*

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State*

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Zip Code*

Briefly explain your current living situation.*

Do you have children?*

Yes

If your children are school-aged, what school district are they in?

How many people in your household need housing EXCLUDING YOU?*

Please enter a number less than or equal to 10.

Have you previously been in a shelter or housing program?*

Yes

Shelter name and contact number*

Veteran?*

One or more persons in my household currently serve in the US Military (Active Duty or Reserves/National Guard)

One or more persons in my household is a US Military Veteran

N/A

PDP Questionnaire

Employment:*

No job

Part-Time

Full-Time Temporary

Full-Time Permanent

Full-Time Permanent with Benefits

I am willing and able to work a full-time job. Employment is required to participate in the program. Income from SSI, SSDI, and child support are not viable.*

Yes

Are you capable of living in a shared environment with other families?*

Yes

Income:*

No Income

Cannot pay for basic needs

Basic needs > $200 Mo PSF

Basic needs and pay rent

Can pay fair market rent

Budgeting:*

Frequently overspends

Infrequently overspends

+- $100 within budget

+- $50 within budget

+- $20 within budget

Savings:*

No savings

<$1,000 - not consistently saving

>$1000 - consistently saves

>$2,500 - consistently saves

>$5,000 - consistently saves

Childcare:*

I need childcare.

I have unreliable childcare.

Childcare is available, but it is unaffordable.

I have childcare with a subsidy.

I have quality childcare without a subsidy.

N/A

Healthcare Coverage*

No Medicaid or other coverage

Medicaid application pending or awaiting out of state transfer

Some members have medical coverage

All members can get medical care when needed, but may strain budget

All members are covered by affordable/adequate health insurance

Adult Education*

No high school diploma or GED

Enrolled in GED program - has sufficient command of English language

Completed high school diploma/GED

Enrolled in job-specific training to improve employment opportunities

Obtained certification/license to practice a particular job (ie cosmetology license or medical coding)

Transportation:*

No access or no license

Limited access - have license and insurance

Vehicle is unreliable - have license and insurance

Vehicle needs minor repairs - have license and registration

Vehicle in good repair - have license and insurance

Emotional Wellbeing*

In last 6 months, I have had thoughts of harming myself - severe difficulties

In last 6 months, no thoughts of harming myself - but severe difficulties

I am unhappy and dissatisfied with life

Sometimes negative feelings, but positive most of the time

Occasional challenges, but I can live life to the fullest

Support from Family/Friends*

No support from family/friends

Family/friends desire to show support, but lack the resources to

Receives support from friends, but not family

Strong support from family or friends - household members support each other's efforts

Healthy support network; household is stable, with open communication

Parental Custody*

Children not in parental custody

Currently involvement of CPS/Family court system

Currently receiving court-mandated services from DSS or other community partners

Family intact with shared custody agreement

Family intact with primary custody

N/A

Children's School Attendance*

One or more school-aged children not enrolled

One or more school-aged children enrolled with 10 or more unexcused absences

Enrolled, but one or more children with 5-9 unexcused absences

Enrolled with fewer than 5 unexcused absences

All school-aged children enrolled and attending on regular basis (no unexcused absences)

N/A

Food and Nutrition*

No food or means to prepare it

Household is on food stamps

Can meet basic food needs without food stamps, but requires occasional assistance

Can meet basic needs - does not require additional assistance

Can choose to purchase any food the household desires

Spiritual Wellbeing*

Most of the time, life seems meaningless/my choices don't really matter.

I do believe life is meaningful, but I'm paralyzed by worry.

I feel consumed by some worries, but I'm trying to live a life that reflects my values.

I believe there is a meaning or purpose for my life, but I have yet to discover it.

I have discovered my purpose in life; I am experiencing the fulfillment God intends for me.

Do you or any of your family members have special health needs?*

Yes

Please explain the special health needs.

Do you suffer from mental health issues?*

Yes

Have you been told by a doctor that you have any of the following mental health concerns? Please check all that apply.

Depression

PTSD

Bi-Polar

Anxiety

Schizophrenia

Eating Disorder

Personality Disorder

Other

Please explain the mental health issues.

Have you ever been treated for alcohol or substance abuse?*

Yes

Please explain the alcohol or substance abuse.

Are you currently fleeing domestic violence?*

Yes

Has your family experienced domestic violence in the past?*

Yes

Have you ever been convicted?*

Yes

Pets:*

I do not have a pet.

I have a pet and I am willing to leave it in someone else's care.

I have a pet and I am NOT willing to leave it in someone else's care.

Are there any past or present medical concerns, which would prevent your ability to sustain employment?*

Yes

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Do you own a car?*

Yes

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Do you have a valid driver's license?*

Yes

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Please upload your latest bank statement.

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

We would like to see your expenses and income.

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If you are unable to provide your latest bank statement, please explain why.

Household Members

Household Member #1 Name*

Household Member #1 Birthdate*

Household Member #1 Age*

Please enter a number from 0 to 100.

Household Member #1 Race*

Household Member #1 Gender*

Household Member #2 Name*

Household Member #2 Birthdate*

Household Member #2 Age*

Please enter a number less than or equal to 100.

Household Member #2 Race*

Household Member #2 Gender*

Household Member #3 Name*

Household Member #3 Birthdate*

Household Member #3 Age*

Please enter a number less than or equal to 100.

Household Member #3 Race*

Household Member #3 Gender*

Household Member #4 Name*

Household Member #4 Birthdate*

Household Member #4 Age*

Please enter a number less than or equal to 100.

Household Member #4 Race*

Household Member #4 Gender*

Household Member #5 Name*

Household Member #5 Birthdate*

Household Member #5 Age*

Please enter a number less than or equal to 100.

Household Member #5 Race*

Household Member #5 Gender*

Household Member #6 Name*

Household Member #6 Birthdate*

Household Member #6 Age*

Please enter a number less than or equal to 100.

Household Member #6 Race*

Household Member #6 Gender*

Household Member #7 Name*

Household Member #7 Birthdate*

Household Member #7 Age*

Please enter a number less than or equal to 100.

Household Member #7 Race*

Household Member #7 Gender*

Household Member #8 Name*

Household Member #8 Birthdate*

Household Member #8 Age*

Please enter a number less than or equal to 100.

Household Member #8 Race*

Household Member #8 Gender*

Household Member #9 Name*

Household Member #9 Birthdate*

Household Member #9 Age*

Please enter a number less than or equal to 100.

Household Member #9 Race*

Household Member #9 Gender*

Household Member #10 Name*

Household Member #10 Birthdate*

Household Member #10 Age*

Please enter a number less than or equal to 100.

Household Member #10 Race*

Household Member #10 Gender*

If we are not able to provide you with services at this time, do we have your permission to share your information with other agencies that could possibly assist you?*

Yes

Date

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Untitled

First Choice

Second Choice

Third Choice

Phone

This field is for validation purposes and should be left unchanged.

HOUSING APPLICATION

Housing Screening

PDP Questionnaire

Household Members