Name
Location
Is finding shelter a problem for you?
Yes
No
How long have you been in your current living situation?
Have you ever been in the Armed forces?
Yes
No
Sleeping arrangements
shelter
apartment
hotel
boarding house
room rental
hospital
nursing home
jail
indoor pubic place
outdoor public place
abandoned building
friend/family's home
car
How satisfied are you with your living arrangement?
Rows
Terrible
Unhappy
Mixed
Satisfied
Delighted
Place
Privacy
Amount of space
Freedom
Cleanliness
Protection fro weather
Safety
Cost
Sleeping arrangements
shelter
apartment
hotel
boarding house
room rental
hospital
nursing home
jail
indoor pubic place
outdoor public place
abandoned building
friend/family's home
car
Has anyone talked to you about how to find a permanent place to live?
Yes
No
Has anyone talked to you about how to find job opportunities?
Yes
NO
What people or pets do you have in your life?
Yes
NO
Do you have a way to earn money?
Yes
No
Is getting enough food a problem for you?
Yes
No
What gives you the most help to live life?
Ways you get food-
purchased meals
found food
any other?
Shelter/mission food
Family/Friend provided
Other
In the past 30 days, have you
Been robbed
Been attacked/ assaulted
had a difficult time findning a place to wash your clothing
had a difficult time finding a place to wash yourself
Had a difficult time finding a place to bathroom
Other
Clothing
Rows
Terrible
Unhappy
Mixed
Satisfied
Delighted
Clothes you're wearing
Opportunity to wash clothing
Ability to replace clothing
Tell me about your health
Tell me about how you feel
happy
hopeful
mad
Upset
Worried
Joyful
Other
Back
Next
Save
Tell me about a time you felt elated
Should be Empty: