Housing Stability Assistance Form

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Housing Stability Assistance Form

Personal Information

Full Name of the head(s) of household*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Family Composition*

Current Housing Status*

Emergency Contact Information*

Housing History

Previous housing situation*

Duration of current housing challenge*

Previous eviction history (if applicable)*

Current living conditions*

Financial Information

Income and Employment Status*

Income Source*

Monthly Income (approximate)*

Monthly Expenses*

Long answer

Existing Debt*

Eligibility for Financial Assistance*

Housing Preferences and Needs

Preferred housing type*

Desired Location *

Budget for Housing*

Special Housing Needs*

Barriers to Housing Stability

Specific challenges preventing housing stability*

Legal issues*

Health or safety concerns that may affect housing*

Current Support and Resources

Participation in other assistance programs *

Existing support networks*

Referrals or recommendations from other social services agencies or counselors*

Employment and Skill Development

Job training or employment assistance needs (if applicable)*

Yes

No

Interest in financial literacy programs (budgeting, saving, debt management)*

Yes

No

Career goals or work stability concerns that affect housing*

Consent and Commitment

Consent for sharing information with partner organizations for housing assistance

Yes

No

Willingness to participate in financial planning, job training, or other related services

Yes

No

Commitment to follow-up check-ins and maintaining communication during the housing process

Yes

No

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