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Pre-Application Form

A Place On Dunaff is currently accepting pre-applications for its affordable housing program. Please fill out this form completely and someone will follow up with you when housing becomes available in your area.

SUBMITTING THIS FORM DOES NOT GUARANTEE YOUR SLOT IN THE HOUSING PROGRAM.

YOUR NAME *

YOUR EMAIL *

YOUR PHONE NUMBER *

WHO ARE YOU APPLYING FOR? *

CLIENT'S NAME *

CLIENT'S E-MAIL (IF AVAILABLE)

CLIENT'S BIRTH DATE

WHAT IS THE CLIENT'S PRIMARY LANGUAGE? *

WHAT IS THE CLIENT'S MARITAL STATUS? *

CLIENT'S GENDER *

CLIENT'S CURRENT LIVING SITUATION *

Homeless shelter
Homeless(i.e. Street)
Hospital
Private Residence
Residential Care/Treatment
Single Room Occupancy

REASON FOR LEAVING *

HAS THE CLIENT BEEN HOMELESS WITHIN THE LAST SIX MONTHS?

Yes
No

IS THE CLIENT AT RISK OF HOMELESSNESS? *

Yes
No

HOW MANY OF THE LAST 30 DAYS HAS THE CLIENT BEEN IN A CONTROLLED ENVIRONMENT? *

WHAT TYPE OF HOUSING IS THE CLIENT LOOKING FOR? *

Veteran Housing
Transitional Housing (from jail, etc.)
Elderly Care Housing
Special Needs Housing
Sober Housing
Independent Senior Living
Student Housing
Other

BEDROOM TYPE THE CLIENT IS INTERESTED IN? *

Private Bedroom
Shared Bedroom
No Preference

DOES THE CLIENT SMOKE? *

Yes
No

DOES THE CLIENT HAVE A VIOLENT CRIMINAL RECORD? IF YES, EXPLAIN *

IS THE CLIENT ON PROBATION OR PAROLE?

IS THE CLIENT DRUG FREE & SOBER?

IS THE CLIENT ON PRESCRIPTION MEDICATION? *

DOES THE CLIENT HAVE MEDICAID? *

WHAT DOES CLIENT NEEDS HELP WITH? (CHECK ALL THAT APPLY). *

Housing
Paying Rent/Utilities
Securing Benefits
Medical Care
Shopping / Meal Prep
Money / Debt Management
Education
Mental Health Services
Opening a Bank Account
Hygiene
Substance Abuse
Taking Medication
Cleaning
Legal Assistance
Health and Wellness Services
Other

CLIENT'S EMPLOYMENT STATUS *

Employed full-time
Employed part-time
Unemployed - looking for work
Not in labor force

HIGHEST GRADE COMPLETED: *

WHICH BEST DESCRIBES THE CLIENT'S MONTHLY INCOME? *

WHAT IS THE CLIENT'S FUNDING SOURCE? *

IF OTHER INCOME SOURCE - PLESE EXPLAIN

NUMBER OF MINORS DEPENDENT ON INCOME? *

DOES THE CLIENT RECEIVE STATE FOOD ASSISTANCE? *

IS THE CLIENT WORKING WITH AN AGENCY, CASE MANAGER, OR SPONSOR? *

IF SO,WHAT IS THEIR PHONE NUMBER OR CONTACT INFO?

WHO REFERRED YOU TO A PLACE ON DUNAFF? *

Case Worker
Nursing Facility
Probation/Parole
Self
Google Search
LinkedIn

ARE YOU INTERESTED IN MAINTAINING A SOBER LIFESTYLE? *

Yes
No
Not Sure

WHAT DO YOU THINK IS THE CLIENT'S BIGGEST OR MOST CHALLENGING ISSUE? *

WHAT SPECIFIC ASSISTANCE OR SUPPORT WOULD BEST HELP THE CLIENT REACH THEIR GOALS? *

IS THERE ANYTHING ELSE YOU WOULD LIKE TO TELL US ABOUT YOURSELF OR THE CLIENT? *

WHEN WOULD THE CLIENT NEED TO MOVE IN? *

ANY OTHER COMMENTS OR QUESTIONS?

A Place On Dunaff Is Affordable, Shared & All
Inclusive housing For Those In Need

GET IN TOUCH

If you have any question or need more information about our services, please feel free to contact us we will get back to you ASAP.

➔ aplaceondunaff@gmail.com

What we do

A Place on Dunaff provide affordable, shared, and all inclusive temporary housing to self-sufficient individuals who need specialized support so they can focus on becoming their better self.

© 2023 Aplace On Dunaff.