Name
First Name
Last Name
Phone
Please provide a phone number where we may safely contact you.
(###)
###
####
May we leave a voicemail message at the number provided?
Yes
No
If no, please give the best time of day to call:
How did you hear about Daffodil Ministries?
If yes, please provide your caseworker's name and phone/email:
Is English your preferred language?
Yes
No
If no, please identify your preferred language:
Are you over the age of 18?
Yes
No
If no, are you an emancipated minor?
n/a
Yes
No
Please describe your current living situation:
Is your current living situation safe?
Yes
No
If no, please explain:
Please list all of the individuals who will be living with you:
For each individual, please give their name, age, relationship to you, and any special needs or accommodations, if any.
Do you have any pets, companion animals, or service animals?
No
Yes
If yes, please describe:
Are there any areas where you cannot or will not live?
Yes
No
If yes, where?
If we are unable to provide housing assistance, and you are placed on a waiting list, where will you live?
Are you currently seeking housing as a result of leaving an abusive relationship?
Yes
No
If yes, where is your abuser currently?
If yes, when was your last contact with them?
If yes, do you and your abuser have children together?
Yes
No
If yes, what is your current visitation plan, if any?
If yes, please describe:
Do you have landlord references?
Yes
No
Have you ever been evicted before?
Yes
No
If yes, when and where?
Please give the source and amount per month of your current income, including any housing vouchers or other public assistance you receive:
Do you believe you are able to rent an apartment in your own name?
Yes
No
If no, please explain:
Are you able to pay a security deposit?
Yes
No
If no, please explain:
Are you able to place utilities in your own name?
Yes
No
If no, please explain:
Besides housing, what are your biggest needs (Examples: daycare, finding a job, furniture, finding a mentor)?
Please add any other information you think is important for Daffodil Ministries to know about you, your family and your situation:
I state that the information provided above is complete and accurate.
*
Please select:
Yes
No
