Housing Stability Assessment Your Name(Required) Email(Required) The last place you lived(Required) What made you leave?(Required)Have you been on a lease before?(Required) Yes No How did that end?(Required) Can you get a positive landlord reference?(Required) Yes No Have you had any past evictions?(Required) Yes No Have you lived in public housing or Section 8 before?(Required) Yes No How did that end?(Required) Do you owe money to a housing authority?(Required) Yes No Do you know if you have any landlord debt (past due rent, utilities, etc?)(Required) Yes No About how much?(Required)Housing GoalsWhere would you like to live next?(Required) Is there an area where you want to avoid (due to domestic violence or recovery needs)?(Required) Yes No Where do you have any friends or family?(Required) Where is your childcare set up? Your children’s schools? Job Options? Transportation? What kind of housing are you looking for?(Required) Do you need any special accommodations?(Required) Yes No What special accommodations do you need?(Required) What size unit?(Required) What monthly rent are you trying to target?(Required)How much do you think you can afford each month?(Required)What is your regular monthly income?(Required)Housing ChallengesHave you tried applying for a new lease recently?(Required) Yes No Where?(Required) What was the outcome? What did they tell you about your application?(Required)Do you have any concerns about moving back into your own place?(Required) Yes No What are they?(Required) Have you taken a family management class?(Required) Yes No Are you willing to take a family management class?(Required) Yes No Assets To Aid In Finding Stable HousingDo you have a job?(Required) Yes No Where?(Required) Have you applied for a job?(Required) Yes No Where?(Required) Can you share proof of looking for a job?(Required) Yes No Do you have any other source of income?(Required) Yes No Have you approached any other agency for housing assistance?(Required) Yes No Have you approached any other agency for employment assistance?(Required) Yes No A short-term housing is limited to 30 days, two weeks at a time. Any request for an extended stay over the 30 days must be submitted in writing one week prior to the end of your hotel stay to allow for approval process. Any breaking of hotel rules will result in eviction from the hotel and it will also prevent any further hotel stays. Your hotel stay is reserved for you and your household members as outlined in your HSS application. No other individuals should be allowed in your hotel room. WE DO NOT PAY FOR ANY INCIDENTALS. Should you incur these while you are a guest at a hotel, you will be held responsible for those charges. You will also be held responsible for any damage caused to your hotel room or hotel property during your stay. Please respect these rules of HSS and the hotels.Please sign with your full signature.(Required)I understand and agree to the terms specified.Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.