Full Name Date of Birth Email Contact Number Gender Male Female Non-Binary Prefer Not to Answer Preferred Pronouns He/Him She/Her They/Them Other Emergency Contact Name Emergency Contact Phone Number Relationship to Emergency Contact Are you currently experiencing homelessness? Yes No What led to your current situation? Eviction Domestic Violence Financial Hardship Medical Issues Other If Other, Please Specify Do you currently have a safe place to stay? Yes No How long have you been in your current situation? Less than 1 week 1-4 weeks 1-3 months Over 3 months Do you have any medical conditions or disabilities we should be aware of? Yes No If Yes, Please Specify: Are you currently taking any medication Yes No If Yes, Please Specify: Do you have any allergies? Yes No If Yes, Please Specify: Do you require any mobility devices such as wheelchair, cane, or walker? Yes No If Yes, Please Specify: Do you require a translator? Yes No If Yes, Please Specify: Are you able to perform Personal Hygiene Independently? Yes No If No, Please Specify: Are you able to maintain a room in a tidy manner independently? Yes No If No, Please Specify: Are you able to Shower or Bath independently? Yes No If No, Please Specify: Are you able to use the restroom or toileting facilities independently? Yes No If No, Please Specify: Are you able to dress yourself independently? Yes No If No, Please Specify: Are you able to feed or eat independently? Yes No If No, Please Specify: What services are you seeking? Emergency Shelter Meals / Food Assistance Medical Support Counseling or Mental Health Services Employment Assistance Other If Other, Please Specify: Do you have any children or dependents requiring shelter? Yes No Are there any active restraining orders or legal issues we should know about? Yes No If Yes, Please Specify: Have you ever been asked to leave another shelter? Yes No If Yes, Please Specify: By signing below, I confirm that the information provided is accurate and truthful to the best of my knowledge. I understand tat submittign this application does not guarantee admission to the shelter and that additional information or an intake interview may be required. Click here to accept Today's Date Signature: Submit
