JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
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.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Phone Number
*
Your answer
Email
*
Your answer
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Please list other Adults and Children in Household and ages of household members (if none write none in the box)
*
Your answer
Household income Sources
*
SSDI
SSI
Employment
Other
Required
Monthly Household Income
*
Your answer
Household Characteristics (please check if any apply to yourself or anyone in household)
*
Mental Health
Veteran
Youth (18-24)
Was ever in Foster Care
Victim of Domestic Violence
Substance Abuse
Physical Health Issues
Pregnant
None of the above
Required
House Characteristics (please check if any pertain to you our anyone in household)
*
*Legal Issue Pending
*Probation/Parole
*Felonies
*Past Evictions
None of the above
Required
Provide information on any of the above * that you checked (charges, dates, and where, if none write none in your answer)
*
Your answer
Household Service Need
*
Rental Assistance for an Eviction
Emergency Shelter
Street Outreach
SNAP Assistance
*Other
Required
If *other please describe
Your answer
How long in Mohave County?
*
Your answer
If less than 90 days in Mohave County, where was the last City and State you resided?
Your answer
Optional: Briefly describe the issue causing you to seek assistance
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
