Safety Screening Form

Please complete the safety screening form only after you have either submitted an online application or after it has been confirmed that you are on the waiting list. If you have any questions, please call our Housing Office at (206) 838-0610 to speak to a staff member.

We want to be sure that we are providing a safe community for our families, so for that reason, we ask every family who requests housing the following safety questions.

Please speak with our Housing Office if you answer yes to any of the following questions:

Do you or anyone in your family have or are interested in pursuing a protection order, restraining order, or no contact order or have concerns of this nature?

Are you or anyone in your family currently involved in the criminal justice system, either temporarily furloughed or on parole?

Are you or anyone in your family currently involved with Child Protection Services or under investigation for child abuse or neglect or domestic violence?

Fields marked with an * are required

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Applicant Information

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Please note that if you are from outside of the United States, you do not have to fill out this background form.

Last Name *

First Name *

Middle Name

Enter any previous maiden names if applicable

Enter any other previous names if applicable

Birthdate *

Relationship to Patient *

Physical Address

Address 1 *

Address 2

City *

State *

Zip / Post Code *

Email *

Phone *

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Patient Information

Patient's First Name *

Patient's Last Name *

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By typing your name in the box below, you are providing us with an official electronic signature and consenting to a background check by RMHC.

Type your full legal name here to electronically sign this form *

Today's Date *