Journey to Housing Pre-Screen Application - Journey to Housing

Name: *
Email: *
Cell Phone: *
Street Address: *
City: *
State: *
ZIP Code: *
Time Zone:
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Journey to Housing Program
A Special Work of St. Vincent dePaul

Mission Statement: 
To witness to the Gospel as we accompany families in Western Wayne County on their journey to housing and to self-sufficiency.

Values
Witness to the Gospel: by our speech and our actions we attest to the truth of the Gospel. Commitment: to the Families Experiencing Homelessness. We stand with and accompany families on their journey to housing. Reverence: We honor the sacredness and dignity of each person. Stewardship - We hold ourselves accountable to the resources entrusted to our care.

Journey to Housing Program Description: 

The Journey to Housing (JTH) Program is a Catholic Ministry under St. Vincent DePaul Detroit  that helps homeless families living or working in Western Wayne County obtain a place to call home.  The goal is to help families learn life-long strategies that result in stable housing for the future. 


Your First name and Last Name: 

{"type":"text","name":"__generic","width":70,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"First and Last Name"}


{"type":"text","name":"__generic2","width":12,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item.","placeholder":"Age"}

{"type":"text","name":"__generic3","width":25,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"Date of Birth "}

Sex: 
{"type":"radio","name":"__generic4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}



Your Marital Status SelectSingleMarried and Living TogetherMarried but no longer living together DivorcedNot Legally Married but Living Together{"type":"select","name":"__generic5","width":50,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nSingle\nMarried and Living Together\nMarried but no longer living together \nDivorced\nNot Legally Married but Living Together"}


Spouse/Significant Other: 

{"type":"text","name":"__generic6","width":75,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"First and Last Name or N/A if single/you don't want to live with them. "}


{"type":"text","name":"__generic7","width":12,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"Age"}

{"type":"text","name":"__generic8","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"Date of Birth "}

Sex: 
{"type":"radio","name":"__generic9","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}




Required For Journey's : 

Please read our requirements for our program: here and initial that you have read our requirement: {"type":"text","name":"__generic10","width":20,"value":"","size":"Small","validation":"NE","validationMessage":"Initials required. ","placeholder":"Type Initials "}

 

1. Children: Please list the children who will be living with you:

Child's 
Last Name
Child's 
First Name
Date of Birth
Sex  Age
Applicant  has Legal Custody  City of School Attendance
{"type":"text","name":"__generic21","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Our program requires children, please fill in this item if you are eligible.","placeholder":""}

{"type":"text","name":"__generic22","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Our program requires children, please fill in this item if you are eligible.","placeholder":""}

{"type":"text","name":"__generic23","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Our program requires children under 18 please fill in this item if you are eligible.","placeholder":""}

SelectMF{"type":"select","name":"__generic24","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Our program requires children please fill in this item if you are eligible.","options":"Select\nM\nF"}

{"type":"text","name":"__generic25","width":100,"value":"","size":"Small","validation":"TI","validationMessage":"Our program requires children under 18 please fill in this item if you are eligible.","placeholder":""}


SelectYN{"type":"select","name":"__generic26","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}

SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic11","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}

{"type":"text","name":"__generic28","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic29","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic30","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic31","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic32","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic33","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic12","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}


{"type":"text","name":"__generic35","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic36","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic37","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic38","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic39","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic40","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic13","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}


{"type":"text","name":"__generic42","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic43","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic44","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic45","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic46","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic47","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic14","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}


{"type":"text","name":"__generic49","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic50","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic51","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic52","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic53","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic54","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic15","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}


{"type":"text","name":"__generic56","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic57","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic58","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic59","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic60","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic61","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic16","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}


{"type":"text","name":"__generic63","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic64","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


{"type":"text","name":"__generic65","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectMaleFemale{"type":"select","name":"__generic66","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale"}


{"type":"text","name":"__generic67","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


SelectYN{"type":"select","name":"__generic68","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\nY\nN"}


SelectCantonDearbornDearborn HeightsGarden CityInksterLivoniaNorthvillePlymouthRedfordWestlandOnline SchoolHomeschooled Not School Age Other{"type":"select","name":"__generic17","width":100,"value":"","size":"Small","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nCanton\nDearborn\nDearborn Heights\nGarden City\nInkster\nLivonia\nNorthville\nPlymouth\nRedford\nWestland\nOnline School\nHomeschooled \nNot School Age \nOther"}



Have you had any involvement with CPS (Child Protective Services): 
{"type":"radio","name":"__generic34","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo\nYes-but over ex-partner"}

{"type":"textarea","name":"__generic41","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Type N/A if you listed no above. ","height":80,"placeholder":"Please type details about your CPS Case or type n/a if you haven't had a CPS Case"}


2. Homelessness: 

Are you homeless?
{"type":"radio","name":"__generic48","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo- but will be evicted in next 15 days\nNo- I don't qualify for the program"}



What are the circumstances that led you to being homeless: 
{"type":"textarea","name":"__generic55","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


What is stopping you from renting an apartment or home today: 
{"type":"textarea","name":"__generic62","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



How long have you been homeless?
{"type":"text","name":"__generic69","width":15,"value":"","size":"Small","validation":"TI","validationMessage":"Please fill in this item.","placeholder":""}

# of Days
{"type":"text","name":"__generic70","width":15,"value":"","size":"Small","validation":"TI","validationMessage":"Please fill in this item.","placeholder":""}

# of Months
{"type":"text","name":"__generic71","width":15,"value":"","size":"Small","validation":"TN","validationMessage":"Please fill in this item.","placeholder":""}

# of Years 

Where are you living now?
{"type":"checkbox","name":"__generic72","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Family\nFriends \nVehicle\nCamper \nMotel/Hotel \nShelter\nNot Homeless"}



Where did you Stay Last Night: 

{"type":"textarea","name":"__generic18","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Please list the full address (i.e Street Number, Street Name, City and Zip Code) of where you stayed last night. "}

3. Employment & Income:

In our program, the more verifiable income you have the better. Please list your employer as well as your spouses/significant other's income if they are going to be living with you. 
Current  Employer Name and Position
Who's Working For this Employer? Street Address including City and Zip  
Start 
Date 
# of hours working per week 
Current Wage
{"type":"textarea","name":"__generic78","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item ","height":40,"placeholder":"Employer Name "}

{"type":"textarea","name":"__generic79","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"Please fill in this item ","height":40,"placeholder":"Position Title "}

{"type":"radio","name":"__generic80","width":100,"value":"","size":"Small","validation":"C1","validationMessage":"Please choose one of the above options.","options":"Me\nSignificant Other\nSpouse"}

{"type":"textarea","name":"__generic81","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item ","height":80,"placeholder":""}


{"type":"text","name":"__generic84","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"If you are not employed, please type \"none.\" ","placeholder":""}

{"type":"text","name":"__generic85","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"If you are not employed, please type \"none.\" ","placeholder":""}

{"type":"text","name":"__generic86","width":100,"value":"","size":"Small","validation":"NE","validationMessage":"If you are not employed, please type \"none.\" ","placeholder":""}

 
{"type":"textarea","name":"__generic82","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item ","height":40,"placeholder":"Employer #2 Name "}

{"type":"textarea","name":"__generic83","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item ","height":40,"placeholder":"Position Title "}

{"type":"radio","name":"__generic87","width":100,"value":"","size":"Small","validation":"C1","validationMessage":"Please choose one of the above options.","options":"Me\nSignificant Other\nSpouse"}

 
{"type":"textarea","name":"__generic88","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item ","height":80,"placeholder":""}

 
{"type":"text","name":"__generic89","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

 
{"type":"text","name":"__generic90","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

 
{"type":"text","name":"__generic91","width":100,"value":"","size":"Small","validation":"","validationMessage":"Please fill in this item.","placeholder":""}



Bridge Card for Food: 
{"type":"text","name":"Inc1","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item. If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}

Income from Job #1 (Be sure to add both paychecks if you get paid 2 times a month) 
{"type":"text","name":"Inc2","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item. If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}

Income from Job #2 (Be sure to add both paychecks if you get paid 2 times a month)
{"type":"text","name":"Inc3","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item. If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}

Income from SSI/SSD
{"type":"text","name":"Inc4","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":" If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}

Child Support: 
{"type":"text","name":"Inc5","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item. If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}

Other Income Such as Door Dash, Amazon Flex, Side Business Etc 
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Type N/A if you don't have any side hustle income. ","placeholder":"Description of the Income Type"}


{"type":"text","name":"Inc6","width":25,"value":"","size":"Normal","validation":"TI","validationMessage":"Please fill in this item. If you receive no monies from this source please type 0 ","placeholder":"$ Per Month "}


Total Income per month (This is calculated for you): 
{"type":"computed","name":"__generic94","width":15,"value":"","size":"Normal","validation":null,"validationMessage":null,"formula":"Inc1+Inc2+Inc3+Inc4+Inc5+Inc6","hidden":false}


How did you hear about Journey to Housing: 
{"type":"checkbox","name":"__generic98","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Internet Search\nLocal St. Vincent DePaul Conference \nSocial Worker \n211\nOther"}




Assessment of Consent:
Journey to Housing will conduct a criminal background check to proceed with the housing process. Expungements are accepted. Do you consent? 
{"type":"radio","name":"__generic107","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}



Journey to Housing will conduct a credit report assessment to proceed with the housing process. Do you Consent? 
{"type":"radio","name":"__generic108","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}



Journey to Housing will conduct drug testing to proceed with the housing process, if needed. Do you consent? 
{"type":"radio","name":"__generic109","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}



Next Steps: 
1. I will reach out to you via e-mail in usually within 15 business days. Please check your spam. Will you check your spam? 
{"type":"radio","name":"__generic111","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes"}



CERTIFICATION 

I certify that the answers to the above questions are true and complete to the best of my knowledge and belief, and I understand that a knowingly false or incomplete answer may be grounds to disqualify me from consideration for, or participation in, the Journey to Housing Program. 

Please use your finger to sign if on a smart phone/ tablet. If on a computer you can use a mouse or the touchpad. 
{"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please type your name as a e-signature.","height":50}