Housing Vulnerability Assessment Questionnaire
Use this form to assess housing stability, identify vulnerability factors, and understand support needs for follow-up.
Household and Housing Situation
Current housing status
*
Renting
Owning
Staying with family or friends
Temporary accommodation
Shelter
Unhoused
Other
Household size
*
ZIP / postal code or neighborhood
Housing Vulnerability Assessment
Vulnerability Factors
*
Risk of eviction
Behind on rent
Overcrowding
Unsafe conditions
No fixed address
Frequent moves
Utility shutoff
Domestic conflict
Inaccessible housing
Other
Severity or Urgency by Domain
*
Rows
Low
Moderate
High
Critical
Safety
1
2
3
4
Stability
5
6
7
8
Affordability
9
10
11
12
Access to services
13
14
15
16
Overall Housing Stability / Vulnerability
*
1
2
3
4
5
Additional Housing Stressors
Needs and Follow-up
Immediate concerns or notes
Preferred follow-up method
*
Phone
Email
Text
In-person
No follow-up
Best time to contact
Submit
Should be Empty: