Intake Application

All fields marked with an asterisk (*) are required. Sensitive fields are encrypted in transit and at rest.

Privacy Notice: Fields marked Sensitive are stored with additional encryption and accessed only for eligibility determination.

Personal Information

First Name *

Last Name *

Date of Birth * Sensitive

Last 4 Digits of Social Security Number * Sensitive

Only the last 4 digits are required for identity verification.

Contact Information

Phone Number *

Email Address

Household & Housing

Monthly Household Income Sensitive

Current Housing Status *

Supporting Documents

Supporting Documents (optional)

Optional. Attach up to 3 documents — for example a photo ID, a benefit award letter, or proof of income. Accepted formats: PDF, JPG, or PNG. Maximum file size: 10 MB per file.

I consent to share my information with partner agencies for the purpose of housing placement and supportive services. *

By submitting, you confirm that all information is accurate to the best of your knowledge. Your data is protected under our Privacy Policy.