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Describe how Judy House can be a fit for your transition. Please also consider visiting our
resource page
in the meantime, as there may be a waiting list.
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* Indicates required question
Full Name
*
Your answer
Current age
Your answer
What is your phone number?
*
Your answer
What is your email address?
Your answer
Current location (sheltered or unsheltered)
*
Choose
Sheltered (hotel, couch surfing, facility, waiting eviction, etc.)
Unsheltered (car, woods, behind a business, etc.)
How many times experiencing homelessness in last 3 years?
*
First
2
3
Other:
Required
I have been (check all that apply)
in jail or treatment
in a motel or extended stay
unable to find affordable housing
enrolled in accountability court
in an abusive or domestic violence situation
evicted or nearly losing housing
asked to leave (was only temporary)
staying in woods
staying in my car
staying outside or behind business
staying with family/ friends
Other:
my challenge in finding housing is:
felony/ past conviction
unable to afford
I am physically disabled
I am on the Registry
I am out on bond/ calendar call
just out of treatment/ recovery
past domestic dispute charges
I have never had any on my own
I have to complete accountability court
no friends or family to help
Prior eviction(s)
Clear selection
Marital Status
Choose
Single
Single / children
Married
Married w/ children
Separated
Who is nearest family relationship you keep, and how would you describe that person?
Your answer
Who is the furthest family relationship and how would you describe that person?
Your answer
On a scale of 1 - 5 how is your mental health?
Poor
1
2
3
4
5
Good
Clear selection
On a scale of 1 - 5 how is your physical health?
Poor
1
2
3
4
5
Good
Clear selection
How are you supporting yourself?
*
Choose
Employed
Disability/ Social Security
Unemployment
Family/ friends aid
Panhandle
No income
No answer
Other
If you answered "no income" please explain.
Your answer
Have you recently been released from a facility? (Hospital, jail, prison, crisis center, rehab)
No
Maybe
Hospital
jail
prison
crisis center
rehab
Are you in need of compliant housing due to specific charges?
Yes
No
Maybe
Clear selection
Are you currently on bond or court proceedings?
Yes
No
Maybe
Clear selection
What are your initial thoughts about entering a Christ-centered transition program? (answer does not exclude anyone)
Your answer
Do you have any specific food allergies?
Your answer
How did you hear about Judy House?
*
Your answer
What is your long term plan for transitioning into sustainable housing?
Your answer
How long do you feel you need to stay in our transition program to accomplish that?
Your answer
Why do you believe that Judy House is a good fit for you and your transition?
Your answer
List any concerns or questions at this time that could be answered by phone or email.
Your answer
How may we contact you?
*
Phone
Email
Submit
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