Designed Future Housing Questionnaire
THIS QUESTIONNAIRE MUST BE COMPLETED IN ORDER TO BE CONSIDERED FOR HOUSING. Be detailed, factual and raw with your responses. Don’t add a lot of details. Just list the facts. Your answers will remain confidential.
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1. Your First and Last Name: *
2. Your Email Address: *
3. Your Phone Number: *
4. Emergency Contact Information *
Please list the name and phone number of someone we can contact in the event of an emergency.
5. Your Age: *
6. Sex: *
7. Race *
8. Do you have children? *
9. In what areas of life do you struggle? Which areas in life could use improvement? (CHECK ALL THAT APPLY.) *
Required
10. Are you currently employed? *
11. If you're employed, what kind of job do you have? *
12. When was the last time you drank alcohol? *
Please provide the exact date.
13. When was the last time you used drugs of any kind? *
Please provide the exact date.
14. Income: *
Check All That Apply
Required
15. What is your current housing situation? *
16. Do you have a Michigan Bridge Card *
17. Have you had interaction with any type of emergency services within the past year? *
Required
18. Were you previously in jail or prison in the last year? If "Yes" please describe what you were charged with. *
Required
What crime were you charged with?
19. Do you currently have health insurance? *
Required
20. What is your current health condition? *
Check All That Apply:
Required
21. Please list any medications you are currently taking. *
22. What is your height? *
23. What is your current weight? *
24. Do you currently smoke cigarettes? *
Has anyone ever told you that you snore loudly? *
25. If you currently smoke cigarettes, how many do you smoke on a daily basis?
26. What are some of your current spiritual or religious beliefs? *
28. What is the status of your support system? These would include family and friends. (Check all that apply) *
Required
29. Which of the following statements are accurate or true about yourself? (CHECK ALL THAT APPLY.) *
Required
Please indicate the emotions you have felt within the past 2-3 weeks: *
Check all that apply.
Required
That's it! You're finished! Simply click the "SUBMIT" button, and we'll be in touch!
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