Housing Interest & Intake Form

Applicant information

Full name *

Preferred name

Date of birth

Age

Phone number *

Email address *

Current address (if any)

Emergency contact

Name

Relationship

Phone number

Housing need

I am… *

What type of housing are you seeking?

Shared furnished room (2 residents per room)Private furnished roomEntire unit (if available)Unsure — discuss options

Desired move-in date

How long do you anticipate needing housing?

Preferred counties

Select any counties that work for you.

Current housing status

Referral information

How did you hear about DALS?

Referral agency (if applicable)

Referral contact name

Phone / email

Income information

Current monthly income

$

Employer name (if applicable)

Income source(s) — select all that apply

Rental assistance

Are you receiving or applying for any rental assistance?

YesNo

Background information

Have you ever been evicted?

YesNo

Have you ever been convicted of a felony?

YesNo

Are you currently on probation, parole, or post-release supervision?

YesNo

Accessibility & support needs

Do you have mobility limitations?

YesNo

Do you require a first-floor room?

YesNo

Do you use any of the following?

WalkerCaneWheelchairNone

Household information

Will anyone be moving with you?

YesNo

Community resource needs

Check any services you may be interested in.

Anything else?

Additional notes (optional)

Certification

I certify that the information provided is true and complete to the best of my knowledge. Submission of this form does not guarantee housing placement. Housing is offered based on availability, eligibility, and program requirements.

DALS, LLC Housing Interest & Intake Form

Applicant information

Emergency contact

Housing need

Current housing status

Referral information

Income information

Rental assistance

Background information

Accessibility & support needs

Household information

Community resource needs

Anything else?

Certification