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HOUSING APPLICATION
Housing Application Eng
Tillman Ross
2019-04-24T14:23:45-04:00
"
*
" indicates required fields
Housing Screening
Name
*
First
Middle
Last
Email
*
Phone
*
Birth Date
*
Month
Day
Year
Your Age
*
Please enter a number from
16
to
100
.
Gender
*
Male
Female
Are you pregnant?
*
Yes
No
When are you due?
*
Month
Day
Year
Are you receiving prenatal care?
*
Yes
No
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
Are you currently homeless?
*
Yes
No
Where did you last live?
*
With friends or family
Shelter
In a rented apartment
In a home that I own(ed)
Other
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.
Please select the city you reside in.
*
Concord
Harrisburg
Kannapolis
Midland
Mount Pleasant
Other
Hidden
Last known address
*
Hidden
City
*
Hidden
County
*
Hidden
State
*
Hidden
Zip Code
*
Briefly explain your current living situation.
*
Do you have children?
*
Yes
No
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
No
Shelter name and contact number
*
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
No
Are you capable of living in a shared environment with other families?
*
Yes
No
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
No
Please explain the special health needs.
Do you suffer from mental health issues?
*
Yes
No
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
No
Please explain the alcohol or substance abuse.
Are you currently fleeing domestic violence?
*
Yes
No
Has your family experienced domestic violence in the past?
*
Yes
No
Have you ever been convicted?
*
Yes
No
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
No
Hidden
Do you own a car?
*
Yes
No
Hidden
Do you have a valid driver's license?
*
Yes
No
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.
If you are unable to provide your latest bank statement, please explain why.
Household Members
Household Member #1 Name
*
Household Member #1 Birthdate
*
Month
Day
Year
Household Member #1 Age
*
Please enter a number from
0
to
100
.
Household Member #1 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #1 Gender
*
Male
Female
Household Member #2 Name
*
Household Member #2 Birthdate
*
Month
Day
Year
Household Member #2 Age
*
Please enter a number less than or equal to
100
.
Household Member #2 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #2 Gender
*
Male
Female
Household Member #3 Name
*
Household Member #3 Birthdate
*
Month
Day
Year
Household Member #3 Age
*
Please enter a number less than or equal to
100
.
Household Member #3 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #3 Gender
*
Male
Female
Household Member #4 Name
*
Household Member #4 Birthdate
*
Month
Day
Year
Household Member #4 Age
*
Please enter a number less than or equal to
100
.
Household Member #4 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #4 Gender
*
Male
Female
Household Member #5 Name
*
Household Member #5 Birthdate
*
Month
Day
Year
Household Member #5 Age
*
Please enter a number less than or equal to
100
.
Household Member #5 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #5 Gender
*
Male
Female
Household Member #6 Name
*
Household Member #6 Birthdate
*
Month
Day
Year
Household Member #6 Age
*
Please enter a number less than or equal to
100
.
Household Member #6 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #6 Gender
*
Male
Female
Household Member #7 Name
*
Household Member #7 Birthdate
*
Month
Day
Year
Household Member #7 Age
*
Please enter a number less than or equal to
100
.
Household Member #7 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #7 Gender
*
Male
Female
Household Member #8 Name
*
Household Member #8 Birthdate
*
Month
Day
Year
Household Member #8 Age
*
Please enter a number less than or equal to
100
.
Household Member #8 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #8 Gender
*
Male
Female
Household Member #9 Name
*
Household Member #9 Birthdate
*
Month
Day
Year
Household Member #9 Age
*
Please enter a number less than or equal to
100
.
Household Member #9 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #9 Gender
*
Male
Female
Household Member #10 Name
*
Household Member #10 Birthdate
*
Month
Day
Year
Household Member #10 Age
*
Please enter a number less than or equal to
100
.
Household Member #10 Race
*
African American
Caucasian/White
Asian
Hispanic
Native American
Two or More (Mixed Race)
Other
Household Member #10 Gender
*
Male
Female
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
No
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
74972
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