Supported Housing Risk Assessment Form
Assess a resident’s housing support needs, current risks, placement requirements, and urgency for supported housing follow-up.
Applicant Basics
Full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current living situation
*
Sleeping rough
Temporary accommodation
With family/friends
Tenancy
Other
Current support worker or referrer name
Housing Risk Assessment
Immediate housing risk level
*
Low
Medium
High
Urgent
Primary concerns
*
Risk of homelessness
Eviction notice
Domestic abuse
Substance misuse
Mental health crisis
Self-neglect
Antisocial behaviour
Arrears
Other
Support needs rating
*
Rows
No support needed
Low
Moderate
High
Daily living support
1
2
3
4
Mental health support
5
6
7
8
Substance use support
9
10
11
12
Budgeting / tenancy sustainment support
13
14
15
16
Safety planning
17
18
19
20
Urgency of support required
*
Within 24 hours
2–3 days
Within 1 week
Routine
Placement and Follow-up
Preferred Supported Housing Type
*
Shared Accommodation
Self-Contained Unit
Emergency Placement
Step-Down Placement
No Preference
Accessibility or Safety Requirements
Ground Floor
Step-Free Access
Gender-Specific Provision
Pet Accommodation
Quieter Environment
Near Public Transport
Other
Additional Notes for Placement or Follow-up
Submit Assessment
Should be Empty: