Rapid Rehousing Intake and Eligibility
Client Information
First Name
Last Name
Date of Birth
SSN (Last 4 Digits)
Phone Number
Email
Gender
Female
Male
Non-binary
Other
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Housing Situation
Current Living Situation
Literally Homeless
At Risk of Homelessness
Fleeing Domestic Violence
Other
Homeless Since
Previous Address
Household Size
Income & Benefits
Monthly Income (Total)
Income Source(s)
Benefits Received
Eligibility Screening
Disabling Condition
Yes
No
Veteran Status
Yes
No
History of Domestic Violence
Yes
No
Notes