WELD Housing Community Intake Form
This application is for those who are interested in being placed in housing with Weld Seattle.
If you are looking for work or other services call (206) 809-7907 to register for our next Mudroom to become a Weld Member.
First Name
Last Name
Date of Birth
Phone Number
Email
(if you have one)
If we cannot contact you directly, how can we get a hold of you?
Gender Identity
Male
Female
Non-Binary/Gender Fluid
Other
Please specify 'other' gender identity
What is your current living situation?
Correctional Facility
Treatment Facility
Homeless
Other
Other housing situation - please describe
Are you an Alcoholic?
Yes
No
Date of last drink:
Are you addicted to drugs?
Yes
No
Date of last use:
Are you currently in recovery for addiction?
Yes
No
No, and I'm not interested in recovery
What has been your involvement with the legal system?
Currently incarcerated (prison or jail)
Formerly incarcerated (prison or jail)
On probation, parole or community placement
Contact with law enforcement of any kind
None of the above
If currently incarcerated, when are you scheduled for release?
Describe 'Contact with law enforcement'
DOC Number (if currently incarcerated)
Date of Release
Do you have a DOC housing voucher (or will have one after release), or will another organization provide payment for housing?
Yes
No
I'm not sure
Not applicable
If you were referred to Weld, who or what agency referred you?
Contact Information