AMAAD General Housing Application
Interim Housing Referral Form *

Participant Information

Do you have a valid ID? *
What is your gender? *
Did the participant exit an institution (Jail/Prison, Hospital, Foster Care, Detention Center, Residential Care Facility or Substance Use Treatment Facility) within the last 90 days? *
Is the participant conserved or does the participant have a conservatorship hearing pending? *
Is the participant on: *
Ethnicity *
Race *
Do you have the following identifying documents (Check All That Apply) *
Would you be comfortable living in a home where LGBTQ+ individuals are openly celebrated? *

Emergency Contact

Presenting Issue(s). Select all that apply to the participant.

Medical, specify? *
Do you currently pay rent? *
Have you ever been served a late rent notice? *
Have you ever been evicted? *
Do you have any outstanding utility bills? *
Have you ever applied for government-sponsored housing? (i.e. Section 8, Shelter Plus Care, SRO) *
Do you owe any debt to a public agency (i.e. Housing Authority, Child Support, etc.) *
Have you ever committed fraud while receiving housing assistance? *
Have you had any problems with previous landlords? *
ment *
Have you ever lived in a transitional living facility before? *
Are you a student? *
What is your income source? *
In the last 30 days have you used any substances? *
Are you currently or planning on attending any outpatient or mental health therapy? *
Are you currently taking any medications? *
Do you currently have a case manager at any agency? *
Have you ever been convicted of a felony? *
Are you currently on probation or parole? *

Over the past 2 weeks, how often have you been bothered by any of following problems?

For Office Use Only

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