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Please enter your information
and click the Submit button at the bottom.
We'll review your information and
enter it into our database.
Questions? Call us toll-free at 1 (866) 282-3119
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Which
best
describes you?
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I have housing, and need a roommate.
I need both housing and a roommate. |
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Last
Name:
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First
Name:
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Email:
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Address:
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City:
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State:
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Zip
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Phone:
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Date
of Birth:
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MM/DD/YYYY |
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Gender:
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Male
Female |
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Do
you have a disability?
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Yes
No |
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If
so, what is the nature of your disability?
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Developmental Disability
Physical Disability
Mental Illness
Dually Diagnosed
Chronic Substance Abuse
Unknown/NA
Further Description:
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Do
you receive in home support services?
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Yes
No |
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If
yes, how many hours?
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What county are you currently living in?
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Oakland
Macomb
Wayne
Livingston
St Clair
Other
Out Of State
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Are you currently receiving services from community mental health?
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Yes
No |
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If
yes, who is providing your support services?
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Do you have a person you work with at CMH?
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Yes
No |
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Who
is that person?
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Do you have a steady monthly income?
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Yes
No |
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Do
you have your own transportation?
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Yes
No |
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Do
you rely on others for transportation?
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Yes
No |
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If
you rely on others for transportation, which do you rely upon?
(check all that apply)
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Family Members
Friends
Public Transportation
Other:
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What
type of living arrangement do you currently have?
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With a Family Member
Group Home
Supported Independent Placement (SIP)
Adult Foster Care
Independently
Other:
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What is a realistic amount you can contribute to monthly rent and utilities?
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In
what area do you want to live?
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Is
there a specific city or town?
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What else should we know about your desired location?
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Do
you require accessible housing?
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Yes
No |
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If
yes, what are those needs?
(i.e., ramp, walk-in shower, single story house)
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How
would having a roommate help you?
(transportation, provide company,
help around house)
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Do
you have any allergies?
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Yes
No |
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If
yes, what are you allergic to?
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Do you have any animals?
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Yes
No |
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If so, what kind?
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Do
you smoke?
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Yes
No |
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What
do you like to do in your spare time?
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What
do you like most about where you currently live?
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What
do you like least about where you currently live?
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Please describe the living situation you are currently seeking:
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Describe
your ideal roommate:
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Is there any other information you would like to add?
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