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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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