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BraveHeart Housing Intake & Pre-Screening
Full legal name
*
Date of Birth
*
Phone Number
*
What is your current housing situation?
*
Who needs housing?
*
A
Female only
B
Mom + 1 Child
C
Mom + 2 Children
D
Male only
List the full names and ages of everyone who will be moving with you
*
What date would you like to move in?
*
Why do you need shared housing at this time?
*
Preferred location
*
A
Glenwood
B
Chicago
C
Either location
Preferred Placement
*
A
Shared Room
B
Private Room
C
Family Private Room
What is your source of income or funding?
*
A
Employment
B
SSI
C
SSDI
D
VA benefits
E
Pension
F
Unemployment
G
Confirmed Agency Funding
H
Other
What is your total monthly income or approved housing funding amount?
*
List your employer, benefit provider, or funding agency.
*
If you recently accepted a job, what is your scheduled start date, pay rate, and expected weekly hours?
Is there anything that could prevent you from consistently making your residential placement payment?
*
Upload a Valid government-issued photo ID
*
Click to choose a file or drag here
Size limit: 10 MB
Upload proof of income or funding
*
Employed applicants must upload their two most recent check stubs. Benefit recipients must upload a current award letter showing the monthly amount. Applicants must upload a funding letter.
Click to choose a file or drag here
Size limit: 10 MB
Upload proof of SNAP benefits, If applicable
Click to choose a file or drag here
Size limit: 10 MB
Can you live independently without 24 hr personal care, nursing, medication administration, or clinical supervision?
A
YES
B
NO
Can you follow the house rules, including quiet hours, payment requirements, assigned chores, visitor restrictions, no violence, no drugs, no alcohol, and no indoor smoking?
*
A
YES
B
NO
Do you currently need emergency shelter, detox, or crisis stabilization?
*
A
YES
B
NO
Have you previously been terminated from a housing program for nonpayment, Violence, or serious rule violations?
*
A
YES
B
NO
If yes, please explain what happened and explain what happened and what has changed.
Describe any accessibility need or reasonable accommodation you are requesting.
I certify that the information and documents submitted are TRUE and complete. I understand that completing this intake does not Guarantee approval or placement.
*
Click Box
Applicant Signature
*
*
Submit