First Name:   MI:  Last Name:  
1) Do you have an established and appropriate residence?  
2) Do you have birth certificate and social security card and state identification or driver's license?  
3) Aside from being housed in prison or jail, where were you last staying or residing? (Select One)
  • 3a) How long had you been staying there? (Best Guess)    
  • 3b) Were you homeless before you began staying there? (Check 1)   How long?  
  • 3c) Have you ever lived in a homeless shelter or on the streets?  
  • 3d) How long had you been homeless? (Best Guess)  
  • 3e) How old were you when you first became homeless?  
4) In the past 3 years, how many times have you been homeless?  
 5) Do you have any long-term physical, mental or emotional disabilities that substantially limit your ability to
work and/or care for yourself or your children?