Emergency Family Shelter Exit Assessment
Family Information
Head of Household Name
Date
Number of Household Members
Contact Phone/Email
Exit Details
Exit Date
Reason for Exit
Permanent Housing
Transfer to Other Shelter
Left Voluntarily
Evicted
Other
Housing Outcome
Housing Status at Exit
Permanent Housing
Temporary Housing
Other Shelter
Unknown
Destination
Assessment
Were basic needs met during stay?
Yes
No
Partially
Services Accessed
Referrals Provided
Additional Notes
Staff Sign-Off
Staff Name
Signature