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Program & Referral Information

Participant Information

Current Situation & Referral

CURRENT LIVING SITUATION *

HOMELESSSTAYING WITH OTHERSTRANSITIONAL HOUSINGJAIL/PRISON RELEASEHOSPITAL / REHABOTHER

REFERRAL SOURCE (IF APPLICABLE) *

SELFAGENCYPAROLE/PROBATIONHOSPITAL OR TREATMENT CENTERFAMILY/FRIEND

BRIEF SUMMARY OF SITUATION / REASON FOR HOUSING NEED *

Health and Legal Background

Mental health diagnosis:

SUBSTANCE USE HISTORY (IF ANY): *

ALCOHOLDRUGSNONE

IF YES, EXPLAIN:

ARE YOU CURRENTLY ON PAROLE OR PROBATION? (LIST PO NAME/PHONE NUMBER) *

YESNO

ARE YOU A REGISTERED SEX OFFENDER? *

YESNO

Income Information

DO YOU HAVE A SOURCE OF INCOME? *

YESNO

DO YOU HAVE A SOURCE OF INCOME? * (Please check all that apply)

SSISSDIEMPLOYMENTOTHER

MONTHLY INCOME AMOUNT (IF ANY):

Housing Preferences or Needs

ANY DISABILITIES OR ACCOMMODATIONS NEEDED? *

YESNO

IF YES EXPLAIN:

PREFERRED ROOM TYPE: *

SHARED ROOMPRIVATE ROOM (IF AVAILABLE)

CAN YOU LIVE INDEPENDENTLY AND MANAGE YOUR ACTIVITIES OF DAILY LIVING (ADLs) WITHOUT ASSISTANCE? *

YESNO PLEASE EXPLAIN

IF NO PLEASE EXPLAIN: