Housing Intake Form Name * First Name Last Name Phone * (###) ### #### Email Date of Birth * MM DD YYYY Gender * Male Female Have you been recently released from incarceration? * Note: A history of incarceration will not impact your application. Yes No Do you have any accessibility or mental health needs we should be aware of? * Yes No Do you currently have housing? * Yes No What is your current living situation? * Please describe below Do you have a source of income? * Yes No Are you currently connected to a caseworker, social worker, or support program? * Yes No If yes, please share name and agency. Are you open to living in a shared housing environment with others? * Yes No Desired Move-In Date * MM DD YYYY Preferred Method of Contact * Phone Text Email Optional - Additional Details Is there anything else you'd like us to know about your situation or what you're looking for in housing? Thank you!Someone from our team will follow up to schedule a brief 15-30 minute phone or virtual interview. Barrier Free Housing MN is committed to eliminating barriers and offering a supportive space to rebuild.We hope your fresh start begins with us!
