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Housing intake

Tell us what a safer home would make possible.

This short form helps us understand where you are, what your household needs, and what an accessible permanent home could look like. You do not need a veteran ID or a street address to begin.

Private intake No medical details required

01 / Contact

Start with the best way to reach you.

We use this information only to follow up about your housing request.

Enter the name you would like the team to use when following up.

We will use this to follow up about your housing request.

Optional. Share a number only if you would like us to use it for follow-up.

02 / Context

A little context helps us listen well.

Choose the answers that feel right. Prefer not to say is always okay.

Choose the option that best describes your connection. Prefer not to say is available.

Choose the closest fit for the housing support you are considering. Prefer not to say is available.

Choose the closest fit for your current situation. Prefer not to say is available.

03 / Location

Where should home be?

A city, county, region, or state is enough. Please do not share a street address.

A city, county, region, or state is enough. Do not enter a street address.

Choose one option that best reflects your timing.

04 / Household

Who should the home hold?

Share the size of your household and anything practical that would help us understand the fit.

Include yourself.

Optional. Practical household context can help us understand what may work; medical details are not needed.

05 / Accessibility

What would make the home work for you?

Tell us about mobility, sensory, and daily-routine support so the team can plan around the whole household.

Mobility

Movement through the home

What level of mobility support feels relevant?

Choose the closest fit for your household right now.

Which home features would help?

Select any features your team should keep in mind. If you choose occasional or regular mobility support, select at least one.

Sensory

A calmer, clearer environment

Choose the closest fit for your household right now.

Which accommodations would help?

Select any environmental supports that may make a home work better. If you choose occasional or regular sensory support, select at least one.

In-home support

Support with daily routines

Choose the frequency that best reflects your current needs.

Which routines may need support?

Select any areas that would help us plan the right home setting. If you choose an in-home support frequency other than none or prefer not to say, select at least one.

06 / Housing needs

What kind of support are you looking for?

This gives our team a first map of what to explore with you.

Choose at least one housing need

Select any kinds of support you would like the team to explore.

Optional. Share only what feels useful for a first conversation. Do not include medical details, a veteran ID, or a precise street address.

You can choose not to share anything that does not feel necessary. This form does not ask for a veteran ID or precise address.

We will review your request and use it to guide a thoughtful next conversation.