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Intake Application

Intake Application

  • Household

  • Financial Information

  • Max. file size: 50 MB.

    Please upload a valid ID

    Acceptable forms of ID:

    • Driver's License
    • ID Card
    • Passport


    If you don't have any of the above, please stop here and call 919-834-0666.


  • Cash Benefits

  • Non-Cash Benefits

  • Drop files here or
    Max. file size: 50 MB.

      Please upload income document

      Income Documents Include:

      • Last 3 months of pay stubs
      • Work First or Benefits Awards Letters
      • Unemployment Breakdown

        If you don't have any of documents, stop here and call 919-834-0666
    • Employment

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    • Intake ROMA Scale

      Please fill out all sections and submit for signature.

    • Authorization
      We are a participating agency of the North Carolina Homeless Management Information System (HMIS) to collect and report on information about the clients we serve.  We collect personal information directly from you for reasons that are discussed in the HMIS Privacy Practices. We may be required to collect some personal information by law or by organizations that give us money to operate this program. Other personal information that we collect is important to run our programs, to improve services for emergency assistance, and to better understand the needs of persons needing assistance. We only collect information that we consider to be appropriate.
      Additional information may be required of Veteran Applicants

      I/We authorize Passage Home to:

      1. Pull my/our credit and criminal report and review my/our credit file for informational inquiry purposes; and
      2. Contact employers and Landlords/rental references to verify that information submitted is correct.
      3. Contact client at address, telephone numbers, and e-mails provided on the intake form.

      I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, and Section 1001 and will automatically disqualify you from any of our housing and services.

      If all fields aren’t complete, you will not be able to sign.

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