Organization Information
Name of referrer:
Agency:
Program Site:
Street Address:
City:
Zip Code:
Phone number:
Extension:
Fax Number:

Participant Information
First Name:
Last Name:
Gender:
Age:
Address Participant is Moving To:
City:
State:
Zip:
Phone:
Date Participant is to move or moved into above Address:

Brief History of Participant
Reason for homelessness
Fire Doubled Up	Eviction Illness	Lack of income Domestic Violence
Other

Date Participant Lost their Housing:
Date Participant Became Homeless:
How Many Months was the Participant Homeless:
What City Did the Participant live BEFORE becoming Homeless:

Where did the Participant live WHILE homeless:
Family	Friend	Streets	Other
Shelter	Shelter Name:
Program	Program Name:
	Date Entered Shelter/Program:

Household Information
Number of OTHER Adults, besides client living in Household:
Ages of these adults:
Number of Children living in Household:
Ages of these children:
Is the Participant a Single Parent:	Yes     No
How Much does the Participant PAY for Rent:
Participant Income AFCD    SSI    EAEDC Part-time wages   Full-time wages Child Support        Other Is Participant on any form of housing Subsidy: Yes    No If yes, what type:

Furniture/Household Needs
Number of Bedrooms:
Studio Apartment
Single Room
Rooming House
Congregate Living
Please indicate which rooms participant needs assistance in furnishing: Kitchen   Living Room       Bedroom  Qty to furnish: