Need Help?

Name

Email Address

Phone Number

Birthdate

Please check all the areas you are looking for assistance. Please check all the areas you are looking for assistance. Shelter Locations Housing Counseling Employment Addiction Obtaining a Drivers License or Identification Card Obtaining a Birth Certificate Other

If Other please explain

Are you currently homeless? Are you currently homeless? Yes No

How long have you been homeless?

What caused your current homelessness?

Where are you currently sleeping? (cross streets & city)

Where did you live prior to being homeless?

How long did you live there?

Are you currently employed or have income? Are you currently employed or have income? Yes No

If employed, where do you work and how long have you been there?

If yes, how much is your expected monthly income?

Marital Status Marital Status Single Married Divorced / Separated Widow

If you have children in your care please list their names and ages.

Do you have a working vehicle? Do you have a working vehicle? Yes No

Are you receiving Food Stamps / SNAP? Are you receiving Food Stamps / SNAP? Yes No

Do you have health insurance? Do you have health insurance? Yes No

Do you have a substance abuse or alcohol use disorder? Do you have a substance abuse or alcohol use disorder? Yes No

Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No

If yes, please explain when and what it was for.

Have you ever been diagnosed with a mental health concern? Have you ever been diagnosed with a mental health concern? Yes No

Please list any details.

Have you ever been evicted? Have you ever been evicted? Yes No

If yes, please explain when and what it was for.

Do you have a birth certificate in your possession? Do you have a birth certificate in your possession? Yes No

Do you have a Drivers License or Identification Card in your possession? (proof of identity)? Do you have a Drivers License or Identification Card in your possession? (proof of identity)? Yes No

Do you have your Social Security Card in your possession? Do you have your Social Security Card in your possession? Yes No

Please enter the last four digits of your Social Security Number