Housing Support Screening for Services Form
Screening Form is used to screen for specific housing barriers and vulnerabilities. To assist with finding available resources to meet the needs of individuals and/or families in Mohave County  that are in a housing crisis.
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Phone Number
*
Email
*
First and Last Name
*
Date of Birth
*
MM
/
DD
/
YYYY
Age
 *
Please list other Adults and Children in Household and ages of household members (if none write none in the box)
 *
Household income Sources
*
Required
Monthly Household Income
*
Household Characteristics (please check if any apply to yourself or anyone in household) *
Required
House Characteristics (please check if any pertain to you our anyone in household)
 *
Required
Provide information on any of the above * that you checked (charges, dates, and where, if none write none in your answer)
 *
Household Service Need
*
Required
If *other please describe
How long in Mohave County?
 *
If less than 90 days in Mohave County, where was the last City and State you resided?
Optional: Briefly describe the issue causing you to seek assistance
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