Silver Lining Solutions: Safe Shared Living & Guaranteed Rent

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Please fill out this form completely so we can deliver the most relevant service tailored to your needs. Thank you!

Last Name *

First Name *

Date of Birth *

MM/DD/YYYY

Phone *

Please enter a valid phone number.

Do we have permission to text/leave a message on the number provided? *

Yes

No

Email *

example@example.com

Emergency Contact *

Name and Number

Gender

Male

Female

What type of room does the client prefer? *

Shared

Private

When does the client need to be placed?

MM/DD/YYYY

Does the client have stable income?

Yes

No

How much income does the client receives monthly? If none, please type NONE. *

Do the client suffer from mental illness? *

Yes

No

If answered YES, please list mental diagnoses

Type NONE if no mental illnesses.

Is the client disabled? *

Yes

No

If you answered YES, please list disability(s) *

Type NONE if no disability/ies

Does client require a Handicap Accessible living environment? *

Yes

No

Does the client have any open or pending charges? *

Yes

No

If yes, please explain (charges)? *

Have the client been convicted as a Sex Offender (your answer to this question does not disqualify you from our program & services) *

Yes

No

With 1000 ft restriction

Without 1000 ft restriction

Is the client currently on Probation or Parole? *

Yes

No

Do client needs help with recovering from Opioid(s) and/or other drugs and alcohol? *

Yes

No

Is the client currently under any case management or housing program? *

Yes

No

If yes, Name and Number? *

If answered yes, please provide Agent Contact Information

Name, Number, Agency, Email Address

Are you willing to relocate to another state?

How did you hear about us? *

Referral

Social Media

Website

Social Worker

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Great! You are one step closer!

Help us find you the perfect home.

Great! You are one step closer!

Help us find you the perfect home.

GET IN TOUCH

COMPANY

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