Have you ever been sexually abused or a victim of sex trafficking? *
Pflichtfrage
Do you have a car? *
Pflichtfrage
Do you have a case manager or social worker? *
Pflichtfrage
If Yes, Case Manager or Social Worker Name & Phone
Meine Antwort
Do you have any disabilities? *
Do you use any recreational drugs or alcohol? *
If Yes, What is your drug of choice?
Meine Antwort
Where did you spend last night? *
Length of stay in location provided in previous question? *
Housing Status *
Do feel threaten in your living situation? *
Do you have or ever had Section 8/Subsidized Housing? *
Are you currently taking medication for any health concerns? *
If yes, Can you afford your medication? *
Please identify if any of the listed conditions exist. *
Homeless Status *
Have You Been In Contact With Any Homeless Shelters?
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If Yes, What Shelter and Who Did You Speak With
Meine Antwort
Are you employed or have a income? *
If Yes, How much do you make weekly?
Meine Antwort
Do you have your high school diploma or equivalent? *
Are you in a relationship? *
Do you have any legal issues? *
Do you ever think about hurting yourself or committing suicide? *
Do you get upset easily or have anger issues? *
Do you have trust issues? *
Are you depressed? *
Do you have outside family/friend support? *
What services are you looking to receive from our organization to help with your current situation? *
Meine Antwort
If we can't provide the services you are seeking, are you okay with us referring you to other resources/agencies that will be able to support your needs? *
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