Emergency Housing Needs Evaluation Sheet
Applicant Information
Full Name
Date of Birth
Contact Number
Email Address
Household Size
Current Situation
Current Address
Reason for Emergency Housing Need
Current Housing Status
Homeless
At risk of homelessness
Temporary shelter
Other
Urgency & Safety
Level of Urgency
Immediate
Within a week
Within a month
Are there any safety concerns?
Yes
No
If yes, please describe
Special Needs or Requirements
Does anyone in your household have special needs or requirements?
Yes
No
If yes, please describe
Additional Information
Other Relevant Information