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GCS - Housing Application
First Name
Last Name
Email
Date of Birth
Gender
*
Male
Female
Non-binary
Phone
Current Address
Are you currently homeless?
Yes
No
Referral Source. How/Where did you hear about us?
*
Social Media
Case Manager
School
Friend
Other:
What city would you prefer to live in?
Chesapeake
Hampton
Suffolk
Newport News
Norfolk
Virginia Beach
Portsmouth
What allergies do you have?
*
None
Pet
Seasonal
Other
Requested move in date
Driver's License #
Payment Source. How will you be paying your rent?
*
Paycheck from employment
Voucher (Fostering Futures, etc.)
SSI
VA Benefits
Other
Do you have a payee?
Yes
No
Not sure
If your payment source is from employment, please list the name of your employer.
Amount of Payment Source? Type the amount received monthly or bi-weekly.
Do you have criminal legal concerns - felony, misdemeanor, on probation, etc.?
Yes
No
Are you a smoker?
*
Yes
No
Do you have any medical diagnosis/concerns? If yes, please list them.
Do you have any behavioral/ mental health needs that we should be aware of? Please be honest, we are here to help, but need to be adequately prepared, as well
Do you have a child/children?
*
Yes
No
Do you have a case manager/social worker/agency you already work with? Type Yes or No. If yes, please list their name and contact information below.
Social Security Number
Do you have a driver's license?
*
Yes
No
If yes, what is your ID#
Do you own a car?
*
Yes
No
Are you in need of transportation?
*
Yes
No
Submit Application
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