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Full Name:

Email Address:

Phone Number:

Date of Birth (MM/DD/YYYY):

Current Address:

Is this your first time living independently?

Emergency Contacts:

What is your gender identity?

What are your preferred pronouns?

Do you have any health risks or concerns we should be aware of?

Have you ever experienced domestic violence in the past?

What does living in a supportive neighborhood look like for you?

Are you currently in case management?

Will you need case management services during your stay?

Do you have local familial support?

Were you born in Shelby County?

Do you have any concerns about safety or security that we should know about?

Do you have any history of drug use, or do you currently use any drugs?

Have you changed your name legally or otherwise, and are there any accommodations you require related to this?

Do you currently have access to HRT (hormone replacement therapy)? If not, are you interested in gaining access to HRT?

Will you be bringing any pets?

What To Expect After You Apply