Housing Prescreen

Household Information

Make sure to include all household members and their information.
Household Size:
# Adults: * # Children: *
Household Members: (start with self)*
Does any household member have a disability condition?*

YesNo
Disabled Household Members

Literally Homeless
Where did you sleep last night? (i.e., automobile, staying with family, tent, motel paid by?, etc)*
Provide where and city/county.
If motel, who paid?
Where are you planning to sleep tonight? *
Are you living in legally condemned housing?

YesNo
Are you fleeing or attempting to flee Domestic Violence?*

YesNo

Consent for Agency Sharing

EightCAP, INC
Do you consent for me to enter your information into required databases and share certain information that will better coordinate your housing needs. Understand that your consent allows for pertinent information listed to be shared among authorized personnel and partnering agencies to assist with housing stability and to better coordinate your needs as it relates to self sufficiency. This consent may be revoked at any time, through a written statement.
Do You Understand and Consent?

YesNo
Print Name:
Signature

Clear
Date

MonthDayYear
Date
Pit Score:
ACES Score:
Should be Empty: