Pre-Qualification Questionnaire

Disclaimer (must be read prior to pre-screening):

This is the initial process for the Rapid Rehousing, Homeless Prevention, or HDHealth program. Responding to all of the pre-screening questions asked of you does not automatically enroll you in the Rapid Rehousing, Homeless Prevention, or HDHealth program. You must meet eligibility requirements. If eligibility is met, you will then be scheduled to meet with the Intake Coordinator.

Please confirm that you have read and acknowledge the statement above.

Name

First NameLast Name

Date of Birth

Please enter a valid birth date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

Please enter a valid email address.

Do you live in County of Riverside?

If so how long?

Example: 10 months or 2 years

How many in family?

Are you currently experiencing homelessness or at risk of being homeless?

How long have you been in your current situation?

Which program are you acquiring about?

Are you at immediate risk of losing your current housing within the next 14 days?

What is your primary reason for your housing instability? (Check all that apply)

If other please explain

Do you feel safe in your current living situation?

Have you previously been homeless?

If yes how many times in the past three years?

Do you currently have any source of income?

If yes, list sources (e.g., employment, social security, disability, etc)

Do you have access to any of the following resources?

If healthcare box was checked which health plan?

If other, please provide which health plan.

Health Insurance Member ID

Any Chronic Health Conditions?

Any Behavioral Health Conditions?

If you selected Other or Substance Use Disorder to the above question please Specify

Do you have any physical or mental health conditions that may be impacting your housing situation?

If yes, please provide a brief description