Faith First Independent Housing Program Agreement

Faith First Independent Housing Program Pre-Screen

Full Legal Name

Date Of Birth

Phone Number

Email Address

Current Address

Referral Source

Agency

Family/Friend

Hospital

Case Manager

Outreach Worker

Self-Referred

Other:

Income & Benefits

Do you have a steady source of income?

Yes

No

Primary Source of Income (Check all that apply)

VA Benefits

SSI

SSDI

Retirement/Pension

Employment

Other:

Estimated Monthly Income (Income verification may be required prior to move-in)

Can you pay a one time accountability fee of $300?

Yes

No

How will you be paying your program fee? (accepted payment methods) *

Cash

Cashiers Check/Money Order

Zelle/Cash App

Bank Transfer

Other:

Do you receive SNAP/EBT food stamps?

Yes

No

Independent Living Capacity

Are you able to live independently without daily assistance?

Yes

No

Do you currently receive assistance with daily activities (cleaning, cooking, hygiene, transportation, etc.)?

Yes

No

If yes, please explain:

Are you currently prescribed any medications?

Yes

No

Do you experience difficulty accessing medications (cost, insurance, transportation, etc.)?

Yes

No

If yes, please explain:

Do you require reminders for medications or appointments?

Yes

No

Do you have any mental health diagnoses you would link for us to be aware of? (Optional)

Yes

No

If yes, please explain:

Housing Preference & Accessibility

Preferred Room Type

Shared Room

Private Room

Private Room with Bathroom

No Preference

Preferred Move-In Date

Do you have physical disabilities or mobility limitations?

Yes

No

If yes, please explain:

Do you require a ground-floor or downstairs room?

Yes

No

Do you have reliable transportation?

Yes

No

If no, do you need housing near a public bus route?

Yes

No

Background & Legal History

Have you ever been evicted?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Are you currently registered as a sex offender?

Yes

No

Do you have any pending legal matters or court cases?

Yes

No

If yes, please explain:

Lifestyle & House Expectations

Are you willing to comply with house rules (no drugs, no unapproved guests, cleanliness standards, curfew/quiet hours, respect for others)?

Yes

No

Do you smoke or vape?

Yes

No

Do you consume alcohol?

Yes

No

Do you have any pets?

Yes

No

How would you describe your cleanliness level?

Very Clean

Average

Needs Improvement

Do you have any difficulty sharing space with others?

Yes

No

Additional Information

Why are you seeking housing at this time?

Is there anything else you would like us to know to help with placement?

Emergency Contact Name/Phone Number/Relationship (optional but recommended):

Resident Signature

Resident Name *

Resident Signature *

Clear

Date