Pre-Application for Boarding Home Residency

Personal Information

Today's Date*

Your Name*

First Last

Your Phone*

Your Email

I identify my gender as:*

Your answer will help us to place you in the best living environment.

Male
Female
Genderqueer/Non-binary
Other

If you answered "other," please specify

Are you 18 years of age or older?*

Yes
No

Name of Emergency Contact Person*

First Last

Emergency Contact Phone Number*

Are you a Veteran?*

Yes
No

In what branch did you serve?

Army
Navy
Air Force
Marines
Coast Guard

Do you have a DD-214 form, the Certificate of Release or Discharge from Active Duty?

If you are a veteran, you need to have this form's information for us to help you. You can go to https://www.archives.gov/veterans/military-service-records to request the DD-214.

Yes
No

Household Information

Are you an:*

Individual
Family (more than 1 person) IF SO, STOP HERE. BOARDING HOMES ARE ONLY FOR SINGLE ADULTS

What County are you currently staying in?*

Monmouth County
Ocean County

Household size (including yourself) Must be a single adult for Boarding Home Waitlist. If more than one person, please STOP here and call the numbers below.*

Please enter a number from 1 to 25.

Monmouth County:
If you are a homeless family and seeking housing assistance in Monmouth County, please call the Monmouth County Centralized Intake System at (732) 431-6000 x 4613 or visit http://www.monmouthhsc.org/monmouth-hsc-centralized-intake-system

Ocean County:

If you are a homeless family and seeking housing assistance in Ocean County, please contact Ocean County Village Resources at 732-341-2271 or visit https://www.oceanresourcenet.org/search/village-resources-ocean-county-coordinated-assessment-agency

Your Current Housing Situation

Describe your current living situation:

Do you have a disabling condition that is permanent or expected to be long-continuing?*

Do you have: 1. A physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury; OR 2. A developmental disability OR 3. Acquired Immunodeficiency Syndrome (AIDS) Are you able to manage activities of daily living? Can you bathe and eat independently?

Yes
No
I don't know

If you answered "Yes," please explain:

How much is your monthly income? Please list all sources and amounts.*

Who referred you to HABcore?*

Friend or Family
Church
Agency

Please include name, job title, and phone number*

Have you ever been arrested?

Please note that we complete background checks for all potential residents.

Yes
No

If you answered "Yes," please explain

Is there anything else you feel is important for HABcore to know?

Date

Pre-Application for Boarding Home Residency

Dial 211 if you need emergency housing.

ATTENTION:

THE PRE APPLICATION FORM BELOW IS ONLY FOR SINGLE ADULTS FOR OUR BOARDING HOME WAITLIST

FOR PEOPLE SEEKING APARTMENTS ONLY AND NOT OUR BOARDING HOME PROGRAM -

PLEASE CALL THE FOLLOWING NUMBERS

Personal Information

Household Information

Your Current Housing Situation