Housing & Employment Questionnaire

The information provided below is only used to help find the best housing or employment options to fulfill your needs.

Name *

Age *

Date of Birth *

Phone *

Email *

Are you looking for? *

Housing

Employment

Where would you like to live?

Are you employed?

Yes

No

Are you seeking employment

Yes

No

Are you a person in recovery?

Yes

No

How long have you been in recovery?

Are you interested in sober living?

Yes

No

Are you on SSI/SSDI?

Yes

No

How much is your monthly income?

Do you have money saved?

Do you have any legal problems? (This question will not hinder services.)

If you are human, leave this field blank.

VIVIAN WRIGHT
O W N E R

C: (225) 249-6030 / F: (916) 404-0130
E: reachingout_referralservices@yahoo.com

SERVICES