Housing Assessment (Complete ALL Fields)
(note: only one animal per disability qualifies as a companion/service animal - all other animals would be considered pets)
Emergency Contacts (record in HMIS client profile - under client notes)
In case of emergencies/housing possibility:
Y / NIf yes, when/what housing provider?
Employment - (refer to Employment Specialist ASAP if available/ Get ROI if working with other employment program)
Are you able and wanting to work?
Legal / Criminal History – (run background report)
Health Insurance
Disabilities - (refer to onsite Support Services ASAP - get relevant ROIs, referrals - record info in HMIS)
Substance Abuse
By signing this form, I certify that the information provided is true and complete to the best of my knowledge and belief.