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Housing intake
application.

Tell us about your housing needs. Your application will be reviewed by staff; completing it does not guarantee placement.

How to send your application
Complete the form, review your answers, then download an email draft addressed to thebridgehousingnetwork@gmail.com. Open the draft in your email app and send it. You can also download a text copy and attach it to an email. This website does not send or save applications. Your answers stay in this page until you download them; refreshing or leaving may erase them. Only share information you are comfortable emailing.

01 / Participant information

Fields marked * are required. Social Security numbers are not collected through this online form. Staff can discuss any additional identification needs directly.

Date of intake *Referral agency / name of referrerFull name *Date of birthAgePhone number *Email addressGenderEmergency contact nameRelationshipEmergency contact phone

02 / Current living situation

Current living situation *Other living situation

03 / Referral source (if applicable)

Referral sourceAgency nameReferring contact namePhone / email

04 / Reason for housing need

Brief summary of your situation / reason for housing need

05 / Medical & mental health history

These questions are optional. You may choose to discuss sensitive details with staff instead. Do not enter medical record numbers or upload medical documents.

Medical & mental health historyMental health diagnosis (if any)Substance use history (if any)If applicable, explain

06 / Legal background

Are you currently on parole or probation?PO namePO phone numberAre you a registered sex offender?Additional notes

07 / Income information

Do you have a source of income?Income sourceOther income source / additional sourcesMonthly income amount ($)

08 / Housing preferences or needs

Any disabilities or accommodations needed?If yes, describe the accommodations you needPreferred room type

09 / Independent living & functionality

Our program is designed for individuals who are high-functioning and capable of living independently. This is not a personal care home, nursing home, or assisted living facility. We do not provide medical care, personal assistance, or supervision. You must be able to manage your own personal hygiene and grooming; meal preparation and eating; medication (unless managed by an outside provider); mobility and transportation arrangements; housekeeping and laundry; and daily living responsibilities. If you require medical or personal care services, they must be provided by a licensed outside agency or caregiver, arranged and paid for separately.

Can you live independently and manage Activities of Daily Living (ADLs) without assistance?If no, please explainDo you currently have or need a home health care provider or outside support service?Agency name (if applicable)I understand and agree that this program provides housing only. I will be responsible for my personal care, medical needs, and daily living tasks. I will not hold the program responsible for services outside the scope of independent housing. *Participant initials *Acknowledgment date *

10 / Program agreement preview

I understand that if accepted, I must follow all house rules, expectations, and participate in case management or program-related check-ins. *I acknowledge that violating rules may result in a strike or dismissal from the program. *

11 / Applicant declaration

Type your name to acknowledge this application. The original form is also available below if you prefer a handwritten signature. Office-use fields are completed by staff.

I certify that the above information is true to the best of my knowledge. I understand that this intake does not guarantee placement, and my application will be reviewed by staff. *Participant name / typed signature *Date *I choose to share this application with The Bridge Housing Network at thebridgehousingnetwork@gmail.com by email. I understand it may include sensitive information, and that downloading a draft does not send my application. *

Download original blank form

Review before sending

Check your answers below. Your application has not been sent. Choose an option below to prepare your email.

Using Gmail in your browser? Download the text copy, then start an email and attach that file. You must send it from your own email account.

Housing intakeapplication.

Review before sending

Housing intake
application.