Pre-Qualification Questionnaire

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.*

Yes
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Please enter a valid birth date
Phone Number*
Please enter a valid phone number.
Email*
Please enter a valid email address.
Do you live in County of Riverside?*

YesNo
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?*

YesNo
How long have you been in your current situation?*

less than 1 month1-3 months3-6 monthsMore than 6 months
Which program are you acquiring about?*

Homeless Prevention / Utilities helpRapid ReHousingHealth
Are you at immediate risk of losing your current housing within the next 14 days?*

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

EvictionDomestic violenceJob loss or reduction in hoursSubstance abuse issuesFamily conflict or breakdownDischarged from hospital, jail, or another institutionOther
If other please explain
Do you feel safe in your current living situation?*

YesNo
Have you previously been homeless?*

YesNo
If yes how many times in the past three years?
Do you currently have any source of income?*

YesNo
If yes, list sources (e.g., employment, social security, disability, etc)
Do you have access to any of the following resources?*

Food assistance (e.g., SNAP, food banks)Healthcare/Medicaid/MedicareTransportation assistancePublic benefits (e.g., TANF, unemployment benefits)Section 8
If healthcare box was checked which health plan?*

MolinaInland Empire Health Plan (IEHP)Other
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?*

YesNo
If yes, please provide a brief description
Should be Empty: