Family Homelessness Assessment

Household Information

Head(s) of Household Name(s) Age(s) Contact Information Number of Adults in Household Number of Children in Household Children's Ages

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Current Living Situation

Current Location / Address Type of Living Situation Emergency Shelter Staying with Friends/Family Hotel/Motel (not paid by agency) Unsheltered (car, park, street) Other If Other, Please Describe Length of Current Homelessness Cause(s) of Homelessness

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Income & Employment

Current Income Sources Total Monthly Household Income Employment Status (All Adults)

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Health & Well-being

Does anyone in the family have health/mental health needs, disabilities, or require accommodations? Describe Any Urgent Needs

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Support & Services

Currently working with any agencies, case managers, or programs? What assistance does your family need most?