Project Legacy

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Fill out the form below to apply for housing at Brockton Bungalows. A contact will get back to you soon!

Basic Information

Legal Name

Services Requested

Services Requested at Intake (check all that apply):


Personal Information

Note: All information requested is voluntary, however some questions may be required to determine eligibility.

Do you speak and understand English?*

If no, what language are you most comfortable speaking?

If another adult is applying for services with you, please list their full name and relationship to you:

Personal Information, cont'd.

For HOPWA Programs

If no, reason?
If no, reason?

Income and Employment

Income and Employment, cont'd.

(Check all that apply)


Criminal History / Police Contact

If yes:

Chronic Homelessness

Note: To assist with this question, have the client look back to the date they last had a place to sleep that was not on the streets or in shelter. You may provide the client with HMIS data to help jog their memory. If the client knows the month and year but not the day, substitute the day of the month with the same day as project entry. Time spent in an institution or treatment facility may be counted if it was less than 90 days.



Health and Disability

This means: do you have a physical, mental, emotional, developmental disability, HIV/AIDS, diagnosable substance abuse problem, or chronic health condition of expected long duration that substantially limits your ability to live on your own?

Health and Disability, cont'd.


All information on this page is required.

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