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Shared Housing Screening Application

Please complete this form to start the screening process. Completion of this form does not guarantee a shared housing licensee agreement with Freedom Way Homes. This process is used to assess appropriateness and eligibility for placement in the most comfortable setting.

Full Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

D.O.B *

What is your sex/gender identification? *

Male

Female

Other

What is the name of the organization that referred you to Freedom Way Homes?

What area (town, city, county, state) are you looking to move? *

Chicagoland Area

Northwest Indiana

Rockford Area

When are you looking to move-in? *

Are you willing to relocate to another area (town, city, county, state)? *

Yes

No

How long do you anticipate a need for this type of housing? *

6-12 Months

12-24 Months

24-36 Months

36-60 Months

How much do you receive as monthly income or support? *

$

Can you make a security/risk fee deposit? *

Yes

No

Are you able to perform Activities of Daily Living? *

Yes

No

Do you have your identification documents? *

Yes

No

Have you ever lived in a shared housing or congregate living situation? *

Yes

No

Do you have an adequate source of food and clothing supplies? *

Yes

No

Do you have any other financial obligations that limit your ability to pay rent? (i.e. student loan, child support, debt, etc.) *

Yes

No

Are you enrolled or willing to enroll in a representative payee program? *

Yes

No

Do you require any special needs assistance? *

Yes

No

Do you have a behavior or mental health diagnosis? *

Yes

No

Are you actively using any mind, mood, behavior altering substance? (i.e. alcohol, cannabis, stimulants, depressants, etc.) *

Yes

No

Are you under State/Federal probation or parole supervision? *

Yes

No

Have you ever been listed at any time on any local, state, or nationwide sex offender list? *

Yes

No

Drug of Choice

Longest Clean Time/ Sobriety Time Ever Achieved

Are you able to provide any personal and/or professional references? *

Yes

No

Do you have any pending legal matters? *

Yes

No

Do you have any vehicles that require parking space? *

Yes

No

Do you have any transportation needs? (getting to/from housing placement) *

Yes

No

Contact Us

[email protected]

+18157062500

3432 W Diversey Ave FL 2, Chicago, Illinois 60647