Diversion Eligibility Questionnaire
Please complete this screening form to help us determine your eligibility for diversion services.
Client Contact Information
Please provide your contact details so we can reach you regarding your eligibility.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Section 1: Immediate Housing Status
Tell us about your current housing situation.
What is your household type?
*
Single Adult, No children (if selected, you are not eligible for assistance)
Single Adult with child(ren)
Two Adults, No children (if selected, you are not eligible for assistance)
Two adults, with child(ren)
Where did you sleep last night?
*
Own apartment/home
Staying with family/friends
Hotel/Motel
Emergency shelter
Car/Street/Unsheltered
Other
Do you have a safe place to sleep tonight?
*
Yes
No
If no, where do you plan to sleep tonight?
Are you facing eviction within 14 days?
*
Yes (eviction notice provided)
Yes (eviction notice not provided yet)
No
If an eviction notice has been provided, please submit below.
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Section 2: Safety Screening
Help us understand any safety concerns you may have.
Is your current living situation unsafe due to:
*
Domestic violence
Threats
Substance abuse in home
Overcrowding
None
Section 3: Housing Problem Solving
Let's explore possible solutions for your housing situation.
Are you being asked to leave your current place of residence?
*
Yes – by landlord
Yes – by family/friend
No
Is there anyone you could temporarily stay with (family, friends, church, etc.)?
*
Yes
No
If yes, who and for how long?
Section 4: Income and Sustainability
Share details about your income and employment.
What is your current monthly gross income?
*
Employment Status
*
Employed Full-Time
Employed Part-Time
SSI/SSDI
Other
Employment Status - Other (please specify)
Proof of Income (for all household members over the age of 18) - MUST BE A MONTH'S WORTH OF INCOME!
*
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Is income expected to increase in the next 30 days?
*
Yes
No
If selected yes, please provide income verification (ex: offer letter)
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Is housing affordable at 30% of income for your household size? (Please see the table below)
*
Yes
No (if selected, you are not eligible for assistance)
How did you hear about this program?
*
Under 1 Roof Website
Family/Friends
Internet (Google/Social Media)
District 8 Newsletter
Agency Referral
Other
Submit Eligibility Questionnaire
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