Action
Date: Are you homeless?
Date became homeless?
Reasons for homelessness
Residence prior to program entry
[SELECT ONE] A car or other
vehicle Homeownership Unsubsidized rental housing An abandoned building Anywhere outside At a
transportation site Domestic Violence
Situation Emergency shelter
Family member's room, apartment, or
house Foster care home Friend's room, apartment, or house HOME subsidized house or apartment HOPWA subsidized house or apartment Hospital Hotel or motel (paid
for with voucher) Hotel or motel (paid
for without voucher) Jail
Juvenile detention facility Other subsidized house or apartment Permanent housing for formerly homeless Prison Psychiatric
facility Public housing
Section 8 Substance
abuse treatment Transitional housing
for homeless Shelter Plus Care
Other Don't
know Refused
Zip code of last permanent
residence Don't
know
Address of last permanent
residence Don't
know
City of last permanent residence
Don't
know
State of last permanent residence
Alabama Alaska
Arizona Arkansas California
Colorado Connecticut Delaware
District of Columbia Florida Georgia
Hawaii Idaho
Illinois Indiana Iowa Kansas Kentucky
Louisiana Maine Maryland
Massachusetts Michigan Minnesota
Mississippi Missouri Montana
Nebraska Nevada New Hampshire
New Jersey New
Mexico New York North Carolina North
Dakota Ohio Oklahoma Oregon
Pennsylvania Rhode
Island South Carolina South Dakota Tennessee Texas
Utah Vermont
Virginia Washington West
Virginia Wisconsin Wyoming Don't
know Refused
How long did you live at your
last permanent residence? Less than one
week One to two weeks Three weeks to one month Two
to three months Four to Six
months Seven months to one
year More than one year
Don't know Refused
1000
additional characters allowed.
Share form with other Programs?
Share form with what other Programs?
