A'HOI: Attainable Housing Options & Innovation Assessment Form

A'HOI: Attainable Housing Options & Innovation Assessment Form

This form serves as an initial assessment for Haynes Harbour Group, Inc. staff to identify your unique needs and how we can best serve and support you in the re-engagement process. Please complete this form in its entirety, and one of our support navigators will contact you within 48 hours. ALL REQUIRED!
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Month-Day-Year
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Alternate Number*
Please enter a valid phone number.
What 'City' & 'State' do you currently reside in?*
Your Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
What 'Gender' do you identify as?*
What 'Race' do you identify with?*
How long were you incarcerated? DC# (if applicable)*
What were you convicted of? NOTE: Specify if you were convicted of a violent crime, violation of probation or supervised release, convicted of an offense involving a firearm, or if you were convicted of a sexual offense.*
How long have you been released from incarceration?*
What is your 'Highest Level of Education'?*

High SchoolGEDAssociate DegreeBachelor's DegreeMaster DegreeOther
Which 'County' are you applying for?*

Miami-DadeBrowardPalm Beach
Do you have children? If YES, How many? And list their 'Names'*
What are your 'Short Term Goals'? (6 months-1 year) *
What are your 'Long Term Goals'? (2+ years) *
What support services do you need to successfully re-engage into society? (Check all that apply)*

Transitional Housing & Support Services (Life Skills, Financial Literacy, Banking/Budgeting, etc.)EmploymentHealthcare (Medical, Mental, Dental, Sexual Health/Wellness, etc.)Education/Vocational CertificationEntrepreneurial Skills Training/DevelopmentIdentification DocumentsClothing/Hygiene KitsFoodReferral for Legal AssistanceOther
Referred by: *
You're Verified & Protected*
Should be Empty: