Homelessness Risk Assessment Form
Full Name
Date of Birth
Current Address
Contact Number
Current Housing Status
Own Home
Renting
Staying with Others
Temporary / Shelter
No Fixed Address
Primary Source of Income
Employment
Benefits
No Income
Other
Experienced Recent Job/Loss of Income?
Yes
No
At Risk of Eviction/Removal?
Yes
No
Do you have a support network?
Strong
Some
None
Any history of homelessness?
Yes
No
Other Risk Factors/Comments