Shared Housing Preference Form

Shared Housing Preference Form - OH! RRH

First & Last Name*

What is the best way to contact you? Please provide at least one email or phone number*

Date of birth: Enter mm/dd/yyyy*

My Gender*

Select or enter value

Preferred Gender of Housemate*

Select or enter value

Location Preference - pick up to 3

Select or enter value

Are you restricted from living in certain areas?*

Select or enter value

My hobbies include:

Housing Situation 1 - Alcohol use in the home*

Select

Housing Situation 2 - Smoking in the home*

Select

Housing Situation 3 - Drug use in the home*

Select or enter value

Housing Situation 4 - Pets in the home*

Select or enter value

Housing Situation 5 - Children in the home*

Select or enter value

Housing Situation 6 - Friends/Parties in the home*

Select

Housing Situation 7 - Not being neat and clean*

Select

Housing Situation 8 - Loud Music/TV/Noise*

Select

What else would you like us to know about your desired housing situation?

What else would impact your decision to consider shared housing?

Do you have any income?*

Select or enter value

If so, what type of income do you have (such as employment, SSI, SSDI, etc.)*

Have you already identified a potential housemate?

Select

If yes above, who is your preferred housemate?

E Signature

Who is your case manager or if you don't have a case manager, how did you hear about shared housing?*

Case Manager Contact info

Send me a copy of my responses