Homeward Bound of WNC Prevention Services Assessment Form

Are you currently at risk of losing your housing?

If you were impacted by Hurricane Helene and live in Buncombe County, Homeward Bound of WNC may be able to help with financial assistance and short term case management.

Please take a moment to fill out this form so we can determine if you are eligible for our assistance.

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Email *
Full Legal Name *
Home Address *
Phone number *
What is your current monthly rent amount? *
How many individuals live in your household? *
Is anyone in your household a Veteran? *
Are currently receiving any ongoing FEMA or Transitional Sheltering Assistance (TSA)? *
Current household income per month?  *
What is your the name of your Landlord or Property Management company?  *
What is your Landlord's email?
What is your Landlord's phone number? 
How many months are you behind on rent? Amount behind? *
Have you received an eviction notice at this time?

 *
If so, what is the date of eviction court?
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Are you behind on utility payments? If so, how much?
What is the name of the utility company you are behind with?
Have you received a disconnect notice from this utility company? 
What is the date of disconnection from this utility?
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Is there a better day/time to reach you?
Please tell us briefly about your situation and how it is related to Hurricane Helene. *
We now invite you to provide optional feedback for the City of Asheville and Continuum of Care.
The following questions are optional and will not affect your acceptance into Homeward Bound's Prevention Program.  We are aware that current resources for families in situations like yours are limited.  As a community, we are trying to grow the resource options.  Asheville will soon participate in a pilot initiative called Right at Home.  The following questions will inform the system's design.  Your full application will be stored confidentially and only Homeward Bound will have access to them.  Homeward Bound will share the responses to the following questions (without your name or any other identifying information) with the Asheville-Buncombe Continuum of Care, a collective body working to end homelessness in Asheville-Buncombe.  By answering these questions, you consent to Homeward Bound sharing your responses with the Asheville-Buncombe Continuum of Care.
Has anyone in your household ever stayed outside, in an abandoned building, in a vehicle, in a shelter, or in a transitional housing program for 1 or more night?
Are you currently staying somewhere without a written lease like staying with friends or family, renting on a verbal agreement, or staying in a hotel?
Has anyone in your household ever been convicted of a crime?
Does anyone in your household have a chronic physical health condition?
Does anyone in your household have a chronic mental health condition?
Does anyone in your household have a history of substance use?
Has someone joined or left your household in the last 3 months due to things like divorce, military service, incarceration, birth, the need for caretaking, or any other reason?
Do you spend more than 30% of your household's income on rent?
Do you spend more than 50% of your household's income on rent?
Would you be willing to have someone from the Continuum of Care contact you in 45 days to ask additional questions?
A copy of your responses will be emailed to the address you provided.
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