Youth Transitional Housing Screening Form
First Name
Last Name
Date of Birth
Age
Phone or Email
Current Living Situation
Homeless
Couch-surfing
In Foster Care
With Family
Other
How long have you been in this situation?
Reason for Seeking Transitional Housing
Legal Status (if applicable)
Preferred Pronouns
Current Services or Supports Accessed
Any health or accessibility needs?
Emergency Contact Name & Relationship
Emergency Contact Phone