Housing Interest Form What housing program are you interested in? Please Choose a Housing ProgramSupportive HousingAffordable HousingShared LivingYouth Rapid Rehousing Are you currently unhoused or living in a shelter? * Yes No How many people in your family need housing? * What is your annual household income? * No Income$1 - $20k$21 - $30k$31 - $40k$41 - $50k> $50k Do you currently receive any type of housing assistance? * Yes No Do you have a disabling condition such as a serious mental illness, drug or alcohol abuse history, physical disability, medical condition or intellectual disability? * Yes No First Name * Last Name * Phone * Email What is the best way to reach you? Phone Email How did you hear about Samaritan House? * Online SearchReferred by FriendReferred by Another Organization Submit
