Housing Needs Form
The Housing Locator Team will do everything they can to match your client to the right home!
Email address *
Program Type
Client or Head of Household's HMIS ID *
Your answer
SECTION 1 - AGENCY CONTACT INFORMATION
Case Manager or Housing Specialist (CM/HS) working with Client *
Your answer
Agency Name *
CM/HS Contact Number *
Your answer
SECTION 2 - CLIENT INFORMATION
Household Type *
Required
How many adults over the age of 18? *
Your answer
How many children under the age of 18?
Your answer
Are children the same gender?
Will there be a live-in caregiver?
Does Household currently have income? *
If the client has income, how much total household income is received per month?
Your answer
Does the client have an active Section 8 voucher? *
If in SSVF, is the client enrolled in HUD VASH?
Is this client looking for Rehousing after losing a previous unit in the program?
If yes, did the client choose to leave or were they served an official notice?
Would this client be interested in shared- housing opportunities? (Having roommates in a home with other eligible program participants)
SECTION 3 – HOUSING NEEDS
Unit Size *
Required
County of Preference
Please select all counties the client would be interested in. If a specific area is preferred in a county, select the County and specify zip code or area under Other:
Ideally, what is the maximum amount rent the client would like to pay?
Your answer
Amenities needed by household
Check all that apply, limit to those required
Accessibility Notes: (Please do not list client identifiable information)
Your answer
Does household have a service animal(s)?
If yes, does the animal(s) have the required ESA or ADA Certification and Documentation?
Does the household have a pet(s) that are not service animals? *
If yes, how many?
Your answer
If yes, what type of pets and how many?
1
2
3
4
5
7
8+
Dog
Cat
Bird
Fish
Hamster
Bunny
Snake
If a dog(s), what is the breed (whether full or mixed breed) and approximate weight?
If more than one pet, please elaborate for all
5-10 lbs
15-20 lbs
20-30 lbs
30-40lbs
40-50 lbs
50+ lbs
Chihuahua
Pit bull
Retriever
Poodle
Terrier
Boxer
Rottweiler
Shih-tzu
Not Known
SECTION 4 – EVICTION AND CRIMINAL HISTORY
If known, Client's credit score range
Some landlords may require a credit check in order to qualify a client. If known, please select which range applies to your client.
Has the Client ever been evicted from housing or abandoned a unit, with their name on the lease? *
If Yes, approximate month and year of most recent eviction:
MM
/
DD
/
YYYY
If Yes, were any of the evictions due to any of the following?
Does the client have any outstanding balances for utilities or eviction debt? *
How many times has the client been evicted?
Is the Client currently on parole or probation?
Has the Client ever been convicted of a misdemeanor? *
Has the Client ever been convicted of a felony? *
If yes, approximate month and year of the conviction? (if month is unknown, only list year)
Your answer
If yes, city and state of conviction?
Your answer
If yes, did the felony(s) involve any of the following:
Select all that apply
If multiple convictions, how many?
If multiple convictions or additional information, please describe:
Your answer
Your feedback is VERY important to us!
Please let us know if you have any suggestions at this time! Thank you!
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Your answer
A copy of your responses will be emailed to the address you provided.
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