Note: A phone number or email address is needed so that we can reach you.
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Phone Number
Please enter a valid phone number.
Email
example@example.com
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HOUSING INFORMATION
Living Arrangements
*
Homeless
Tent/Woods
Shelter
Hotel
Foster Care
Group Home
Jail
Long-term facility
Rehab Facility
Residential Program
Transitional Housing
Staying with a friend
Staying with family
Section 8 Rental
Rental
Apartment
House
Other
Length of Stay
*
1 night or less
2 - 6 nights
1 week - 1 month
30 - 90 days
90 days - 1 yr
1 year or longer
Other
Living Arrangement - More info
County of Residence
*
Last permanent Address
Are you going to leave your current living situation within the next 14 days?
*
Yes
No
Other
Do you have resources or support networks to obtain permanent housing?
*
Yes
No
Other
Have you moved more than 2 times in the last 60 days?
*
Yes
No
Other
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STATUS
Veteran Status?
*
Yes
No
Other
Gender
*
Male
Femaal
Other
Ethnicity
*
American Indian
Asian
African American
Hispanic
White
Other
Disability Status
*
Yes
No
Type of Disability
*
Physical
Chronic Health Condition
HIV/Aids
Developmental
Alcohol Abuse
Drug Abuse
Mental Health
None
Other
Explain Disability (When did it start, is it long-term?)
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INSURANCE
Health Insurance
*
Yes
No
Other
Type of Health Insurance
Medicaid
Medicare
VA
Employer-Provided Health Insurance
Private Pay
Marketplace
None
Other
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Income
Income Source
*
Employment Income
Unemployment Income
SSI
SSDI
VA
Private Disability Insurance
Workers' Compensation
Retirement Income
Pension
Child Support
Alimony or Other Spousal Support
None
Other
Non-Cash Income
*
Food Stamps
WIC
None
Other
Do you want to work?
*
Yes
No
Other
Can you work?
*
Yes
No
Other
List any barriers to work
List any skills, passions, type of work you would enjoy
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DOMESTIC VIOLENCE
Are you a domestic violence victim/survivor?
*
Yes
No
Other
If yes, when did the experience occur?
*
Within the past three months
Three months to one year
One year ago or more
Other
If yes, are you currently fleeing?
*
Yes
No
Other
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ADVOCATE AGREEMENT
Are you willing to sign a Power of Attorney to allow us to speak on your behalf?
*
Yes
No
Other
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