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