Rapid Re-Housing Eligibility Assessment
Client Information
Full Name
Date of Birth
Phone Number
Email Address
Housing Status
Current Living Situation
Homeless (shelter, street, car, etc.)
Doubled-up (living with others)
At risk of losing housing
Other
How long have you been in your current situation?
Household Members (names, ages, relationships)
Income & Employment
Source(s) of Income
Monthly Household Income
Employment Status
Employed
Unemployed
Other
Barriers & Needs
Barriers to Housing (check all that apply)
Eviction history
Criminal history
Poor credit
Disability
Other Needs