Kauhale Housing Program Application

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Applicant Information

Full Name *

Date of Birth *

Preferred Name (if applicable)

Gender *

Male

Female

Non-binary

Prefer not to disclose

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Household Type *

Single Applicant

Couple

Senior (Age 55+)

Other

Partner’s Name *

Other (please describe) *

Current Living Situation (choose one) *

Unsheltered (car, tent, street, etc.)

Emergency Shelter

Transitional Housing

Couch Surfing/Friends/Family

At-risk of homelessness

Other

Other (please describe) *

How long have you been experiencing houselessness? *

Enter a number and circle days/months/years.

Duration *

Days

Months

Years

Do you have any current housing applications elsewhere? *

Yes

If yes, where? *

Do you have any income? *

Yes

Source(s) of income (check all that apply) *

Employment (Part-time/Full-time)

Social Security/Disability Benefits (SSI/SSDI)

Veterans Benefits

Welfare

Pension

Worker’s Comp

Unemployment

Other

Other (please specify) *

Monthly income amount ($)

Estimate the average amount of earned monthly income over the last 6 months.

Do you receive any of the following assistance? (check all that apply) *

Note: If accepted into transitional living, voucher waitlists may be affected.

SNAP (Food Stamps)

FEMA

Medicaid/Medicare

Housing Voucher (Section 8, etc.)

Other

Assistance — Other (please specify)

Do you currently have a case manager? *

Yes

If so, with what organization? *

Are you interested in case management services? *

Yes

Supportive services you may need (check all that apply) *

Mental/Behavioral Health Services

Substance Use Support

Transportation Assistance

Supplemental Nutrition Assistance Program

Job Training/Employment Assistance

Temporary Assistance for Needy Families

Medical Referrals

MedQuest/Medicare

Child Welfare Services

Women, Infants & Children (WIC)

Housing

Community Court

Financial Literacy/Budgeting Support

Other Legal Issues

Other

Community Court — Details *

Other Legal Issues — Please describe *

Other (Please describe) *

Community Living Preferences

Shared communal spaces (kitchen, toilets, showers) — are you comfortable with this setting? *

Yes

Do you have any accessibility needs? *

Yes

Please describe *

Would you be willing to contribute to the community (chores, gardening, maintenance, etc.), employed and non-employed (volunteered)? *

Yes

Please share skill that you have

What new skills would you like to obtain?

Additional Information

Reason for homelessness (check all that apply) *

Loss of employment

Domestic Violence

Physical or mental disability

Being evicted

Other

Evicted - Please explain *

Other - Please explain *

Ethnicity (check all that apply) *

Caucasian (white)

Alaska Native

Hispanic or Latino

Choose not to disclose

Native Hawaiian

Black or African American

Asian

Pacific Islander

Pacific Islander - specify which one *

Polynesian, Micronesian, Melanesian, or please specify other

Vital Documents (check all that you currently have) *

State I.D. / Passport / Driver’s License

Birth Certificate

Social Security Card

Medical Cards

Paystubs

Checking / Saving Account

Do you own a vehicle? *

Yes

Do you have current vehicle documentation? *

Yes

Do you have any pets? *

Yes

Type of pet? *

Are they up to date with all vaccinations and registrations? *

Yes

If yes, are they spayed or neutered? *

Yes

Have you ever been convicted of any offense against the law, to include lifetime sex offender registration? (Omit traffic violations or offenses tried in juvenile court.) *

Yes

If you answer YES to this question, list each offense, the date and status. Please note, upon submission of the intake form, all community members will undergo a comprehensive background check. *

Is there anything else you would like us to know?

Acknowledgment & Consent

Acknowledgment & Consent *

I certify that the above information is accurate and complete to the best of my knowledge. I understand that this intake form is for initial assessment purposes and does not guarantee housing placement.

Signature *

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