EverNine Placement Inquiry

Section 1: Applicant Information

First Name *

Last Name *

Date of birth *

Gender

Female

Male

Other

Email *

Phone *

Section 2: Current Living Situation

Current living situation *

Section 3: Program Fit

Are you working with any agencies or programs?

Yes (if yes, please give agency name & contact information below)

Are you currently able to live in a drug/alcohol-free, shared housing environment? *

Yes

What is your primary source of income? (Select one) *

Are you currently on probation, parole, or under court-ordered supervision? *

YES (I'll explain below)

Due to legal housing restrictions in some areas, we must ask: Are you currently on any sex offender registry? *

YES

Prefer not to answer (we may follow up for clarification depending on location)

Are you willing to undergo a background check? *

YES

Section 4: Urgency & Preference

Room preference *

Solo room (limited availability)

Shared room

No preference - first available

How soon do you need placement? *

Within 48 hours

Within 7 days

Just exploring

Section 5: Final Notes

Please share anything else you'd like us to know

Disclaimer By submitting this form, I affirm that the information provided is accurate to the best of my knowledge. I understand that EverNine Placement is an independent living program and not a licensed treatment facility or landlord-tenant arrangement.

Certain questions on this form are used solely for program eligibility, placement suitability, and compliance with local housing laws or restrictions. Information regarding legal supervision, criminal history, or registry status will be treated confidentially and evaluated in accordance with applicable laws and public safety requirements.

Submission of this form does not guarantee placement.

By checking this box, I consent to receive communications from EverNine Placement regarding my waitlist status, placement opportunities, program updates, or related services I have requested. Message frequency may vary depending on placement availability or eligibility follow-up. Message and data rates may apply. Reply HELP for assistance or STOP to opt out at any time.