Waitlist – Westwood Group

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Housing Pre Screening Application

Fill out the form carefully for registration

Waitlist

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First Name

Last Name

Date of Birth

Gender

Phone Number

Email

Current Location (City/State)

Are you currently on supervision?

Who referred you? (Caseworker/Agency Name)

Are you willing to share a room?

Yes

No

What is your monthly income amount?

What is your income source?

SSI

SSDI

VA Benefits

Other

If “Other”, please explain:

Do you have a valid ID, SSN, or proof of income?

Valid ID

SSN

Proof of income

Have you ever been convicted of a violent or sexual offense?

Yes

No

If yes, please explain:

Are you currently facing any pending legal charges?

Yes

No

If yes, please explain:

Have you ever been diagnosed with a mental health condition?

Yes

No

If yes, do you have a treatment or medication plan in place?

Yes

No

Are you currently receiving counseling or support services?

Yes

No

Have you struggled with substance use in the past?

Yes

No

Are you currently sober?

Yes

No

If yes, how long?

When are you looking to move in?

How did you hear about us?

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