Emergency Housing Application
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Alias:
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Place of Birth:
*
Are you currently enrolled in another program?
*
YES
NO
If yes, explain.
*
Gender
*
Woman
Transgender-Woman
Non-Binary
Other
Ethnicity
*
Hispanic or Latino
Non Hispanic or Latino
US Citizen?
*
YES
NO
If no, what is your Immigration Status?
*
Are you currently empolyed?
*
YES
NO
Case Manager Contact
Case Managers will be contacted as part of the application process.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Agency
*
Email
*
example@example.com
Homelessness
Must meet the definition of chronic homelessness
Are you currently homeless?
*
YES
NO
How did you become homeless?
*
Date you became homeless
*
/
Month
/
Day
Year
Date
Reason for leaving prior housing?
*
Name of Shelter/Institution you've stayed?
*
Have you ever been evicted?
*
YES
NO
If yes, Date of eviction?
*
/
Month
/
Day
Year
Date
Mental Health History
This does not make you ineligible for housing assistance.
Have you been hospitalized for an emotional or mental condition?
*
YES
NO
If yes, explain:
*
Have you received treatment and/or medication for emotional/mental condition?
*
YES
NO
If yes, explain:
*
Substance Abuse History
This does not make you ineligible for housing assistance.
Do you have a history of substance use?
*
YES
NO
If yes, what is your substance of choice and how often did you use?
*
Ever been treated for any addiction?
*
YES
NO
If yes, explain:
*
AA/NA/GA attendance?
*
YES
NO
If yes, where?
*
Do you have a sponsor?
*
YES
NO
Estimated last date of substance use?
*
Legal History
This does not make you ineligible for housing assistance.
Have you been arrested before?
*
YES
NO
Is there currently a warrant out for your arrest?
*
YES
NO
Have you ever been convicted of a crime?
*
YES
NO
Have you ever served jail/prison time?
*
YES
NO
If yes to any questions above, please explain and list previous arrest record.
*
Are you on probation or parole?
*
YES
NO
If yes, give probation or parole officers name, phone number and the date it ends.
*
References
References will be contacted as part of the application process.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship:
*
Completion of this application does not guarantee housing or supportive services.
Signature
*
Continue
Continue
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