Homelessness Prevention Assessment Form
Personal Information
First Name
Last Name
Date of Birth
Phone Number
Email
Current Address
Household Information
Household Size
Household Member Names, Ages, and Relationship
Housing Situation
Describe your current housing situation
What factors are putting you at risk of homelessness?
Have you received an eviction notice?
Yes
No
If yes, date of eviction
Income & Employment
Employment Status
Employed
Unemployed
Other
Monthly Income
Sources of Income
Assistance Needs
What type of help are you seeking?
Other services you are interested in
Additional Information
Is there anything else you would like us to know?