Tell us more about your housing needs

Name *
Nickname (if preferred)
Phone *
Email *
Date of birth *
Best way to reach you *
Any case manager, social worker, or outreach worker you’re connected with? Name: Organization: Phone/email:

Where are you staying right now?

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How long have you been without stable housing? *
Where did you stay last night? *
Do you feel safe where you’re staying right now? *
Are you trying to stay in this general area, or are you open to other parts of town? *

Do you have any ID with you right now?

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If a home needs to verify your identity, which documents do you have or can get quickly? *

Do you have any steady monthly income right now?

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About how much is it per month, roughly? *

Is the money paid directly to you, or do you have a payee / someone who receives it for you?

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Any pending applications for SSI/SSDI, VA benefits, etc.?

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Do you use any mobility aids? (cane, walker, wheelchair, etc.)

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Can you manage stairs, or do you need a ground-floor setup?

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Do you need help with basic daily activities (bathing, dressing, meals), or are you mostly independent?

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Do you take any medications you manage on your own?

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Are you currently connected to any doctors, therapists, or clinics you want to keep seeing?

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A lot of people are dealing with stress, depression, anxiety, or other mental health issues. Is there anything you’d want a housing provider to know so they can support you better? *

Are you currently in treatment or counseling anywhere?

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Do you use alcohol or other substances right now?

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Have you been recently released from jail or prison?

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Are you currently on probation or parole?

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Do you have any restrictions on where you can live? (Like being near schools, certain areas, or certain people?)

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