Transitional Housing Applicant Screening Form
Section 1: Applicant Information
Best way to reach you if you don’t have a phone or email (e.g., case manager, family member, or friend):
Are you the head of household?*
Section 2: Household information
Are you currently expecting/pregnant?*
Section 3: Special Needs & Background
Do you or any household members have any disabilities or special needs? *
Section 4: Housing Status
Are you currently experiencing homelessness?
HUD: Lacking a fixed, regular, adequate place to sleep, or meeting specific criteria for imminent housing loss, fleeing violence, or homelessness among certain youth and families.*
If homeless, how long have you been experiencing homelessness? *
Section 5: Domestic Violence Assessment
Have you experienced domestic violence?*
Are you currently in a domestic violence situation or fleeing domestic violence?*
Section 6: Safety & Recovery Screening
Are you currently facing charges for, on probation for, or have you ever been convicted of a violent crime?*
Are you currently using drugs or alcohol?*
Are you currently sober?*
(Please note: The use of drugs or alcohol is not permitted on the premises.)
How would you describe your current mental health status?*
