Housing Pre-Application

Pinewoods (1, 2, 3, & 4 Bedrooms Units – Stockbridge)
Forest Springs (1, 2, & 3 Bedroom Units – Great Barrington)
East Street (1 Bedroom Units – Great Barrington)
Prospect Street (2 Bedroom Units – Lee)
Jordan House (Congregate Units – Great Barrington)
Genesis House (Congregate Units – Great Barrington)
Windflower (Single Room Occupancy Units – Great Barrington)

First Name

Last Name

Mailing Address

Town/City

State

ZIP Code

Phone Number

Email Address

Gender Identity

Date of Birth

Race

Ethnicity

Do you or an immediate family member live or work in Southern Berkshire County?
YesNo

How did you learn about Construct?

Current Housing Situation

Total Number of Household Occupants

Number of Occupants Under Age 18

Is your household a housing voucher holder?

Do you have a housing voucher, such as a Housing Choice Voucher (Section 8), VASH, MRVP,
AHVP, Emergency Voucher, or Rapid Rehousing voucher? If so, please list what type(s) below.

ADA (American Disabilities Act) – With the sole interest of determining the
accommodations this organization is required to provide by law, this response is not optional.
Okay with stairsNOT okay with stairsWheelchair access required

Does any household member have a disability as defined under federal fair housing law? A disability is a
physical or mental impairment that substantially limits one or more major life activities.
YesNoPrefer Not to Answer

Do you qualify for and/or receive any of the following? These responses are not required, and
their sole use is to determine the legal eligibility of applicants for supportive housing, should the
applicant require it.

Benefit / Service	Do you qualify or receive this?
SSDI (Social Security Disability Insurance)	YesNoPrefer Not to Answer
SSI (Supplemental Security Income)	YesNoPrefer Not to Answer
SS (Social Security Retirement)	YesNoPrefer Not to Answer
DMH (Department of Mental Health)	YesNoPrefer Not to Answer
DDS (Department of Developmental Services)	YesNoPrefer Not to Answer
CBH (Community-Based Housing)	YesNoPrefer Not to Answer
PCA (Personal Care Attendant)	YesNoPrefer Not to Answer
If yes to PCA – Does the PCA need overnight accommodations?	YesNoPrefer Not to Answer

Annual Household Income – Please list all sources of income in annual format for every
household occupant over the age of 18.

Income Type	Annual Income
Employment 1
Employment 2
Employment 3
Employment 4
Employment 5
Unemployment
Child Support
Alimony
SSA (SSDI, SSI, SS)
TANF (Temporary Assistance for Needy Families)
Pension/Retirement
Regular Gifts
Other
Total Annual Household Income

Optionally, please expand on your current housing situation, and any other information that you find
important to this application process.

Questions can be directed to housing navigator, Kate Coulehan.