Housing Inquiry Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Email *Client's Name *Client's Phone Number *Is your client looking for a shared or private room?Shared RoomPrivate RoomHas the client lived in a shared/co-living home before?YesNoTell me a little about the client (adhere to HIPAA)How long has the client been under your case management?We can provide the environment to be successful. Is there anything else you can tell us about your client?Is your client ok with a no alcohol, no drugs, no overnight guests policy?YesNoIs the client ambulatory (there may be steps)?Is your client able to cook, clean, and perform daily chores?Can the client take needed medications, and schedule any Medical Assistance?Income – Is the client on SSI/SSDI/Voucher or another income source?Does the client have a 3rd party rep payee?Hygiene – Can the client bathe and maintain hygiene unassisted?Who do we call if we notice any changes in behavior, physical, or mental health?We do not provide any services (e.g. – food, transportation), does the client have access to needed services? the a provide Caseworker Phone Number *Your email address *When is your client available for an interview and tour?When would your client like to move in?What organization are you with? *Submit