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DateFirst & Last Name
What pronouns do you use?
She/Her
He/Him
They/Them
Other/Prefer not to say
Contact Phone NumberE-mailWhat is your mailing address?
Are You Homeless
Yes
No
Is this your first time experiencing homelessness?
Yes, first time experiencing homelessness
No, returning from a permanent destination
No, re-engaging from a temporary situation
No, re-engaging from another type of situation
No, continuously homeless
Where are you sleeping today or usally sleep?
Outdoors/streets/parks/encampments
A structure or indoor area not normally used for sleeping
A shelter or navigation center
Vehicle
Other
Obstacles to obtaining permanent housing:
Can't afford rent
No job/Income
No money for moving costs
Housing process too difficult
No housing available
What do you think is the primary event or condition that led to your homelessness?
Lost job
Eviction
Foreclosure
Incarceration
Alcohol or drug use
Illness/Medical problem
Divorce/Separation/Break up
Landlord raised rent
Argument with family or friend who asked you to leave
Family/Domestic Violence
Mental Health issues
Hospitalization/Treatment
Aging out of foster care
Other
Don't know/Prefer not to say
What is Your Case Worker Name, Organization Name and Phone Number and Email Address?
Are you over the age of 65 yrs old?
Yes
No
Are you under the age of 18yrs old?
Yes
No
Ethnicity/Race:
White, Non-Hispanic/Non-Latinx
White, Hispanic/Latinz
Black or African-American
Native American/Alaskan Nativw
Asian
Native Hawaiian or Other Pacific Islander
Other
Unknown/Prefer not to say
Marital Status
Married
Widowed
Divorced
Separated
Single
What language do you mainly speak at home?
English
Spanish
Cantonese/Mandorin
French
Other
What is your source of income?
Government Assistance received:
EBT/Food Stamps/SNAP/WIC/CalFresh
GA/CAAP/CAPI
CalWorks
SSI/SSDI
Medi-Cal/Medicare/Covered CA
Social Security
VA Pension
Not receiving any form of government assistance
Do you have a valid ID?
Yes
No
In progress
Do you require financial assistance acquiring ID?
Yes
No
Do you have a valid social security card or US Citizen authorization?
Yes
No
In progress
Which category below includes your age?
Under 18
18 to 25
26 to 61
62 and older
Which of the following best represents how you think of your gender?
Male
Female
Other
Prefer not to say
If you identify as LBGTQ+, which of the following best represents you?
Bisexual
Gay/Lesbian
Queer
Transgender
Other
Do not identify as LBGTQ+
Are you a veteran?
Yes
No
Have you ever been incarcerated?
Yes
No
Unknown/Prefer not to say
How many people living in your household?Names and ages of all household members:Do you need housing special accommodations? If so, please explain.What County would you like to secure housing?
Do you need any resources for medical, mental, drug or alcohol treatments?
Yes
No
Have you experienced domestic violence during your lifetime?
Yes, previously
Yes, currently
No
Other/Prefer not to say
What is the highest level of school you have completed or the highest degree you have received??
Less than High School Degree
High School Degree or GED
Some college
Trade/Vocational certificate
Associate Degree
Bachelor Degree
Graduate Degree
Which of the following categories best describes your employment status?
Employed, Part-Time
Employed, Full-Time
Not employed, looking for work
Not employed, not look for work
Retired
Disabled, not able to work
Do you have access to a computer?
Yes
No
Are you interested in job training/placement services?
Yes
No
Are there any other resources we can help you with? If so, please explain:
Have you reviewed your credit report within the last 30 days?
Yes
No
Your credit counseling appointment is scheduled on:Your Credit Counselor Name is:Who referred you to our organization?Your Housing Counselor Name:Your next housing counseling appointment is scheduled:Housing Counselor NotesI agree to the Terms & Conditions and Privacy PolicySubmit
