Client Application

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Services
About
Make A Commitment
Contact Us

First Name*

Last Name*

Gender*

Male

Female

Date of Birth*

Phone Number*

Do we have permission to call, message, or text you at the number provided?*

Yes

Email*

Are you currently working with any organization that is providing housing assistance or helping to establish placement into a temporary, long-term, or otherwise transitional or shared housing program? *

Yes

If you answered "Yes" above, please list the name of that organization, name of the rep you are working with, their title, and their phone number. (if applicable)

What is your current living situation*

Living with a friend

Living with family

Living in a shelter

Living in a car

Living on the street

Other (explain in notes below)

Notes - Explain your current living situation. (if applicable)

Are you aware that this is shared living?*

Yes

What type of room do you prefer?*

Shared

Private

No Preference

When do you need to move in?*

How long will you need to stay in transitional housing?*

Less than 30 days

1 - 3 months

4 - 6 months

7 - 12 months

13 - 24 months

Other - Please explain in notes below.

Notes: Explain the length of time needed for transitional housing if not mentioned above.

How will you pay?*

SSI

SSID

Organizational Funding

Private Pay (Job, Unemployment, etc.)

Do you have any known health or behavioral issues that we should be aware of?*

List all medications the you are taking?*

Are you required to register on the sex offender's registry?*

Yes

Tell us about your situation*

Do you have any mental diagnosis? If so, please explain*

How did you hear about us?

You are aware that by entering your signature below you are verifying that all information provided is accurate?*

Yes

Signature: *

Please note that this is an application for consideration to join the waiting list and does not constitute acceptance or guarantee admission into this housing program. Once your application has been received and reviewed, our staff will reach out to you to learn more about your situation.

Empowering individuals through safe transitional housing.

info@atpleasantpath.com

Client Application

Please note that this is an application for consideration to join the waiting list and does not constitute acceptance or guarantee admission into this housing program. Once your application has been received and reviewed, our staff will reach out to you to learn more about your situation.

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