Homeless Intervention Assessment

Homeless Intervention Assessment Form
What county are you in?*
Type of assistance needed?*
Full Name:*
Number of People in Household:*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Employment Status:*

EmployedNot EmployedOther
Income Type:*

SSISSDIPensionRetirementSSAChild SupportTANFUnemploymentEmployment WagesOther
What has been your total household income for the last 30 days (before taxes)?*
Please type the dollar amount $
Receive Public Assistance Programs below?:*

SNAP (FOOD STAMPS)MedicaidMedicareCAPS (Childcare Assistance ProgramSection 8Public HousingNoneOther
Homeless Status:
Where did you sleep last night?*

OutsideShelterCarSomeone Else's HouseHotelApartmentYour Own HouseOther
Do you own or rent your home?

OwnRentN/A
How long have you been homeless?*

Not HomelessClose to becoming homeless1-3 Weeks1 month2 months3 months4+ monthsNot SureOther
Homeless Prevention
How many months are you behind?*

Not Behind1 month2 months3 months4 months5+ months
If behind, what is your total past due amount in $?
Have you received a late notice or eviction notice from courthouse?*

YesNo
If so, please attach a copy of the late notice and/or eviction notice. Also, please attach a copy of your lease if you have it.

Browse Files
Click the button above to attach documents or pictures. Multiple uploads are allowed. Cancelof
Disablility Question
Do you have a disabling condition?*

YesNo
If yes, please mark all that apply.

Alcohol AbuseChronic Health ConditionDevelopmental DisabilityDrug Abuse
HIV/AIDSPhysical DisabilityMental HealthOther
Are you currently receiving assistance completing this form? Examples: ( Sheriff Deputy, Family Member, Friend, Pastor, etc.....)*

YesNo
If so, please list their name and contact information below:
Please list the persons name and phone number of the person helping you.
Should be Empty:

Homeless Intervention Assessment Form