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Contact information
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Name
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Email
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Phone number
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Your answer
Date of Birth
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What is your current housing situation?
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I am currently homeless
I am at risk of losing my housing
I am living in, or I have recently transitioned from, an institution (ex. hospital or nursing home, foster homes, assisted living etc.)
I am eligible for waiver services (BI, CAC, CADI, DD, EW)
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In the past 12 months have you slept in a homeless shelter?
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No
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What is your household size?
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Your answer
How many Bedrooms are you looking for?
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Do you have a criminal record?
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No
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Do you have any disabilities?
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Your answer
Are you employed?
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No
If no, are you interested in employment opportunities?
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No
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Do you have a social worker/case manager?
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No
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