Housing Stabilization Plan Form
Please complete this form to help develop a tailored housing stabilization plan. All information should be accurate and up to date.
Client Full Name
*
First Name
Last Name
Primary Contact Information (Phone or Email)
*
Current Housing Status
*
Housed (stable)
At risk of losing housing
Temporarily housed (e.g., with friends/family)
Homeless (shelter, street, etc.)
Other
Describe Your Current Housing Situation
*
Household Composition (List all household members and relationships)
*
Current Source of Income or Employment Status
*
Full-time employment
Part-time employment
Unemployed
Receiving benefits/assistance
Other
Immediate Housing Risks or Barriers (check all that apply)
Eviction notice
Loss of income
Health or disability issues
Family conflict
Legal issues
Other
Housing Stabilization Goals
*
Support Services Needed
Rental assistance
Employment support
Mental health services
Substance use services
Legal assistance
Other
Preferred Follow-up or Contact Method
*
Please Select
Phone
Email
Text message
In-person meeting
Case Manager Notes or Next Steps
Submit Plan
Should be Empty: