Housing Qualification Form

Thank you for your interest in staying at one of our group homes! To ensure the best possible experience, please take a moment to complete the short questionnaire below. It only takes about 3 minutes, and providing accurate information will help us better meet your needs. We appreciate your time and look forward to welcoming you!

Full Name *

Contact Number *

Email *

Gender *

How do you classify yourself ?

Veteran

Senior

Homeless

Youth out of foster care

Sober Individual

Immigrant

What are you looking for ?

All inclusive Shared room - Starting from 850$ per month

All inclusive Private room - Starting from 1400$ per month

Preferred city in California where you want housing ? *

Do you have pets ? *

Yes

Do you agree to provide ID during intake interview? *

Yes

Do you agree for a drug test ? *

Yes

Do you agree to video recording of the intake interview ? *

Yes

Are you med-compliant (able to take prescribed medications independently)? *

Yes

Are you able to manage your own medication and schedule doctor's appointments independently? *

Yes

Has you lived in a shared or co-living environment before? *

Yes

How many hours a week do you work ? *

Less than 5 hours per week

Less than 10 hours per week

Less than 20 hours per week

40 hours or more

Are you ambulatory (able to move independently)? *

Yes

Do you have experience of a "House Manager" in a shared living facility ? *

Yes

What is the your source of income? *

SSI/SSDI

Housing voucher

Employment

Assistance from a non profit

Other (please specify)

Can you prepare your own meals? *

Yes

Who should we contact in case of changes in the your behavior, physical, or mental health?

Do you have any known allergies or medical conditions that require accommodations? *

Yes

Do you have reliable transportation to appointments or other necessary destinations? *

Yes

Are you and your contacts/guarantors aware of the rules and expectations of group homes (e.g., chores, curfews)? *

Yes

Are you able to maintain personal hygiene and complete basic daily living activities (ADLs)? *

Yes

Do you have any known behavioral issues or history of conflict in shared environments? *

Yes

Are you willing to participate in household chores and maintain cleanliness in shared spaces? *

Yes

Are there any specific concerns or situations we should monitor (e.g., past eviction, disputes)? *

Yes

Are there any legal issues, probation requirements, or pending court cases that we should be aware of?

Yes

Are you involved in any support groups, therapy, or case management programs? *

Yes

Do you understand and agree to the financial obligations, including rent payments and due dates? *

Yes

What steps have you taken to maintain sobriety or recovery? *

What additional support or resources do you need to succeed in this environment? *

Are you willing to sign an agreement acknowledging house rules, expectations, and responsibilities? *

Yes

Do you have a backup plan if they are unable to meet financial or personal responsibilities in the house? *

Yes

Would you be willing to participate in conflict resolution sessions or mediation if necessary? *

Yes

Have you been to jail or prison in past 5 years ? *

Yes

In what year did the crime occur? *

What was the crime ? *

When were you released from jail or prison ? *

Case Manager Name *

Case Manager Phone Number *

Case Manager Email Address

Consent to Receive Marketing Messages
By submitting this form, you agree to receive marketing and promotional messages, including text messages and calls, from Bay Shelter Homes at the phone number you provided. These messages may include updates, special offers, and other information about our locations and availability of beds. SMS/TEXT rates may apply.

Express Consent: I understand that my consent is not a condition of purchase.
Opt-Out: You may opt-out of receiving these messages at any time by replying STOP or contacting our team directly.

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