JADES, Inc. | HR, Referral & Consulting

Housing Request

Pre-Screening Form

This form helps us understand your housing needs. Completing it does not guarantee placement or room availability.

Applicant's Full NamePhone NumberEmail AddressPreferred Area or NeighborhoodPreferred Room TypeMove-In TimeframeMonthly Housing BudgetIncome SourceAble to Live Independently?Existing Caregiver or IHSS Support?Referral Source or Contact (optional)Accommodation Needs or Additional Information (optional)

I understand that this is a preliminary housing inquiry and does not guarantee placement. I give JADES, Inc. permission to contact me and share the housing details I provide with potential housing providers when discussing available options.

Please do not include medical records or a Social Security number.