Housing Intake Pre-Screening Application

Housing Access Network

For questions related to this form, please reach out: chevy.housingaccess@gmail.com · (913) 575-3485

Housing Intake Pre-Screening Application

Your Housing Intake Form is used to collect essential information from individuals seeking housing support through your program. It helps assess eligibility, understand each person’s current living situation, identify barriers to housing, and determine the most appropriate placement or services. The form also ensures accurate contact details, income information, and support needs are documented to support efficient coordination and ongoing assistance.All information collected is kept strictly confidential and is used solely for the purpose of providing housing support and related services.

Your Information

First Name

Last Name

No email available

Date of Birth *

Primary Contact Number *

Include your area code

Secondary Contact Number

Include your area code

Preferred Method of Contact *

Call

Text

Briefly describe your current situation *

Income

Employment Status *

Monthly Income *

Housing Preferences

What is your current housing situation? *

Estimated Housing Date Needed *

How many adults are in your household? *

How many children are in your household? *

How many bedrooms do you need? *

Where would you prefer to be located? *

Placement Fit

Are you able to easily navigate stairs? *

Your answer does NOT disqualify you from housing

Yes No

Do you have a history of substance use? *

Your answer does NOT disqualify you from housing

Yes No

Do you have any evictions? *

Your answer does NOT disqualify you from housing

Yes No

Are you open to Shared Housing? *

Yes No

What type of housing are you open to? *

Single Family House

Apartment

Duplex/Triplex/Fourplex

Sober Living

Do you have any past or pending convictions? *

Your answer does NOT disqualify you from housing

Yes No

If yes, please explain

Are you a Registered Sex Offender? *

Your answer does NOT disqualify you from housing

Yes No

Are you participating in mental health services? If yes, please list the agency.

Your answer does NOT disqualify you from housing