Get placement form

Full Name *

Preffered Name

Date of Birth *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Current Location/City

Emergency Contact

Name *

Phone Number *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

Relationship *

Housing Status

How long have you been experiencing housing instability? *Less than 3 months3–6 months6–12 monthsOver 1 year

Are you a U.S. Veteran? *YesNo

Branch of Service (if applicable)

Do you have veteran documentation (DD-214 or VA ID)?YesNoNot Sure

Are you currently connected to VA services?YesNoWould like assistance

Section 4: Program Eligibility (Check all that apply)

CheckboxHomeless VeteranVeteran experiencing housing instabilityVeteran Medical Foster Care candidateReturning citizen seeking safe re-entry housingIndividual needing structured supportive housingIndividual requiring daily personal careTransitional housing toward independenceOther

Section 5: Medical & Personal Care Needs

Do you currently require daily personal care or medical support?YesNo

If yes, please describe your care needs (mobility, medication assistance, personal care, etc.):

Are you currently receiving care from a provider or case manager?YesNo

If yes, please provide name/organization (optional):

Section 6: Behavioral Health & Safety

Do you have any mental health or behavioral health conditions we should be aware of?YesNoPrefer Not to say

Do you feel able to live safely in a shared group home environment?YesNoWith Help

Section 7: Substance Use Policy Acknowledgment

Are you willing to comply with the program’s substance use policy (substance-free or harm-reduction model)?YesNoWould like more information

Section 8: Returning Citizen Information (If Applicable)

Have you been recently released from incarceration?YesNo

Do you have any legal restrictions that may affect group housing placement?YesNo

Are you currently under probation or parole supervision?YesNo

Section 9: Support & Program Participation

Are you willing to participate in the following as part of your placement?Intake and needs assessmentCase management or care planningLife skills or stability supportHouse meetings and check-ins

When do you need housing placement?ImmediatelyWithin 30 daysFlexible