EA Initial Assessment (Depository)

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Client First Name *

Client Last Name *

Contact Information (phone & email) *

Social Security # (last 4 digits) *

Date of Birth *

年

月

日

Gender *

Male

Female

Transgender Female (MTF or Male to Female)

Transgender Male (FTM or Female to Male)

Gender Non-conforming (i.e. not exclusively male or female)

I do not want to answer.

其他:

Race *

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Other

I do not want to answer.

Ethnicity *

Non-Hispanic or Latino

Hispanic or Latino

I do not want to answer.

Which best describes your current situation? *

Literally Homeless (staying on the streets or in a shelter)

Imminent Risk of Homelessness (received an eviction notice)

I have received a shut off notice for utilities

What is your address w/ zip code or most frequented location?

Are you fleeing or attempting to flee from domestic violence? *

Yes

Veteran? *

Yes

Youth? (24 y/o or younger) *

Yes

Do you have any dependents living with you? *

Yes

Has your housing crisis been directly caused by COVID19? *

Yes

Additional Notes

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