Housing Intake Form for TAP VA
(If you would prefer to print this, right-click the page and select 'print')
What is your name/nickname? *
Your answer
Do you self identify as any of the following? *
What are your preferred pronouns? *
(Please check as many as apply)
Are you over 18? *
Do you have any allergies or dietary restrictions?
Your answer
What are your favorite hobbies?
What do you like to do in your spare time?
Your answer
Are you comfortable around animals/children? *
Have you been prescribed any medication? *
What assistance are you currently receiving? *
Please check all that apply (if none, please check 'other' and answer none)
Have you been homeless in the last 12 months? *
(For this question homeless means that you lacked a fixed, regular, and adequate nighttime residence for more than 1 week. Shelters, cars, a friend's couch, abandoned buildings, parks, and other private/public spaces do not qualify as fixed, regular, adequate residence.)
How long were you homeless?
What are your current living arrangements? *
Your answer
Besides housing, what forms of assistance do you need? *
Do you need to attend any of the following on a regular basis? *
(if none, please check 'other' and answer none)
In what Virginia city / county, do you live or will be relocating? *
Your answer
Do you own or have regular access to a phone or email address? *
We need a way to contact you. Please select all that apply.
What is your phone number? *
This will be our primary way to contact you.
Your answer
What is your email address? *
Email will be used to relay important information and all addresses are kept confidential.
Your answer
Please list your top three emergency contacts (or as many as you can). *
These will remain private and only be used in case of an emergency.
Your answer
Do you have a regular doctor/hospital in case of emergency? *
Your answer
Do you have any triggers that your host should be aware of? *
Please list any that you feel comfortable sharing, they will remain private.
Your answer
If applicable, please list what your host should do to help if you have a panic/anxiety attack or similar issue:
(How can we best help you get through this?)
Your answer
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms