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COVERED BY GRACE HOUSING SOLUTIONS
INITIAL SCREENING/INTERVIEW FORM
APPLICANT INFORMATION
First Name
*
Last name
*
Date of Birth
*
Month
Day
Year
Phone
*
Email
*
Referral Source
BASIC ELIGIBILITY
Are you currently in need of housing?
*
Yes
No
When do you intend moving in?
*
Do you have a source of income currently?
*
Yes
No
PROGRAM UNDERSTANDING
This is a structured, drug, and alcohol-free living environment. Do you understand and agree to this?
*
Yes
No
Are you willing to follow house rules and expectations?
*
Yes
No
Are you open to participating in supportive services (job readiness, life skills, etc)?
*
Yes
No
SUBSTANCE USE SCREENING
Are you currently using drugs or alcohol?
*
Yes
No
Are you willing to remain sober while in the program?
*
Yes
No
Are you currently in recovery or receiving support?
*
Yes
No
BEHAVIOR & SAFETY
Have you had any recent incidents involving violence or aggression?
*
Yes
No
Are you able to live respectfully with others in a shared space?
*
Yes
No
Are you currently on probation or parole?
*
Yes
No
MENTAL HEALTH & SUPPORT
Are you currently receiving mental health support?
*
Yes
No
Do you feel you need additional support?
*
Yes
No
GOALS & MOTIVATION
Why are you seeking housing at this time?
*
What are your goals while in the program?
*
What does independence look like to you?
*
Submit
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