Emergency Transitional Housing

INITIAL ASSESSMENT

Emergency/Transitional Housing

*Referring Agency

*Agency Representative/Contact Phone

*Date of Assessment

Client Demographics

*Last Name

*First Name

*Birthdate

*Social Security #

*Phone #

*Gender

Last Permanent Address

Please select one of the following for current living situations

Homeless with no roof/living in a place not meant for habitation (a vehicle, abandoned building, anywhere outside without shelter)

Homeless with a roof (living with friends or relatives, frequently moving between various living accommodations, no permanent mailing address)

Length of time in current living situation

Contributing Factors to Homelessness

*Please answer the following:

Is current living situation COVID-19 related? (loss of income due to furlough, layoff, or illness)? Yes or No

If no, please list contributing factors (abuse or violence in previous home, asked to leave, family disruption due to death or relationship status, physical or mental illness, loss of income, inability to find employment, etc.)

Level of Assistance Needed

Short-term emergency assistance/hotel stay 1-5 days

Transitional housing up to 30 days

*Client Signature

Household Members

Name:
Social Security #:
Birthdate:
Gender:
Relationship to Client:

Established in 1950, The Housing Authority of Danville is a federally assisted public housing community regulated by the Department of Housing and Urban Development.

1014 Rosemont Avenue
Danville, Kentucky

Monday - Friday
7:30AM - 5:00PM

+1 (859) 236-6116

hadkyinfo@gmail.com