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.
Email Address
*
example@example.com
Section 1: Immediate Housing Status
Tell us about your current housing situation.
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
Are you being asked to leave your current place of residence?
*
Yes – by landlord
Yes – by family/friend
No
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.
Is there anyone you could temporarily stay with (family, friends, church, etc.)?
*
Yes
No
If yes, who and for how long?
Have you discussed a payment plan with your landlord?
*
Yes
No
What financial resources do you currently have available?
*
Income
Savings
Tax refund
Family support
None
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)
Is income expected to increase in the next 30–60 days?
*
Yes
No
Is housing affordable at 30% of income?
*
Yes
No
Signature
Submit Eligibility Questionnaire
Submit Eligibility Questionnaire
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