2. Male ________ Female _________

3. Date of birth? ______________ Age _________

    a. Where were you born? ________________________

    b. How long have you lived in Cherokee County? ___________

    c. Where (geographic location) do you stay the most in the county? _________________________________

    d. Where was your last permanent address immediately prior to becoming homeless? _______________________________________________________

 

4. Ethnic background?

    White ______________     African American _____________

    Hispanic ____________     Native American _____________

    Asian _______________     Other _______________________

 

5. Educational Level                  Highest Grade Completed

    a. Elementary                       _____________

    b. Middle/Junior High            _____________

    c. High School                      _____________

    d. College                            _____________

    e. Trade School                    _____________

    f. Bachelor's Degree              _____________

    g. Master's Degree                 _____________

    h. Professional Degree           _____________

    i. Other (please specify)        _____________

 

6. Are you: Married ___________    Separated ___________

                 Divorced __________   Single _______________

                 Widowed _________

 

7. Do you have any children?    Yes _______ No _______

    a. How many children? _____________

    b. Do your children live with you?  Yes _______ No ______

    c. Ages of children ______ ______ ______ ______ ______

 

8. If you live with other people, with whom do you live?

    a. Live with friends _____________

    b. Live with relatives ___________

    c. Live with spouse _____________

    d. Live with boy _____ girl _____ friend _____

    e. Live with children __________

    f. Live with spouse and children __________

    g. With whomever I can day-to-day __________

 

9. In what do you live?

    a. Shelter __________  (someone has arranged or is paying for you to stay in a motel or shelter temporarily)

    b. Park __________

    c. Car ___________

    d. Vacant building __________

    e. Fields __________

    f. Woods __________

    g. Other (please specify) _______________________________

        ___________________________________________________

 

10. How long have you had this living arrangement?

    __________ Days  __________ Months   __________Years

 

11. What is the cause of your present living arrangement? (check all responses that apply)

   a. Loss of job _________

   b. Eviction __________

   c. Drinking/Drugs __________

   d. Asked to leave __________

   e. Breakup of marriage __________

   f. Violence in the home __________

   g. Released from hospital or institution __________

   h. Released from jail/prison __________

   i. Mental disability __________

   j. Other (please be specific) _________________________

 

12. Are you presently employed?   Yes _____ No _____

    a. If yes what do you do? ___________________________

    b. If, how long have you been unemployed? ___________

    c. Are you looking for work? ________________________

    d. What type of work would you like to do?                

    e. How long ago was you last steady job? ____________

    f. How long did you keep that job? _________________

    g. What type of work do you do? ___________________

 

13.  Are you disabled?   Yes _____  No _____

 

14.  What do you feel keeps you from working full or part-time if you do not work? __________________________________________

 

                                          HOW LONG?          MO. INCOME?

   a. Steady job                     __________          __________

   b. Temporary job               __________          __________

   c. Unemployment insurance __________          __________

   d. S.S.I.                             __________          __________

   e. A.F.D.C.                        __________           __________

   f. Family/relatives             ___________          __________

   g. No income                     ___________           __________

   h. Other (please specify)    ___________          __________

 

16. What other help do you receive? (Check all that apply)

   a. Free rent _____

   b. Clothes _____

   c. Gifts _____

   d. Food _____

   e. Money _____

   f. Pan handling _____

   g. Swaps and trades _____

   h. Food stamps _____

   i. Other (please be specific) _____

 

17. How do you take care of your medical needs for you and your family?

 

18. What type of assistance do you need to become self-sufficient? (Check all that apply)

Place to live _____              Emergency shelter _____

Transitional housing _____    Clothing _____

Permanent housing _____      Food _____

FINANCIAL

Job training _____                 Job referral _____

GED preparation _____           Remedial education _____

Tutoring _____                       Baby sitting _____

Money management _____       Budgeting _____

Housing assistance _____         Housing Counseling _____

 

Psychological therapy _____     Emotional therapy _____

Substance abuse therapy _____ Family counseling _____

Violence counseling _____

 

What is wrong with you physically? (please be specific)

_________________________________________________

Do you need to be in a hospital? __________ Why?

_________________________________________________

 

19. What type of shelter do you need? Please check more than one, if it applys to your situation.

    a.  Immediate (less than a month) __________

    b.  Short term (two - four weeks) __________

    c.  Long term (one month or more) __________

    d.  Permanent __________

 

20. What type of housing do you prefer?

   a. Apartment _____

   b. Motel _____

   c. House _____

   d. Other (please be specific) _____

 

21. Who would you prefer to live with?

    a. Alone _____

    b. Husband or wife _____

    c. Relatives _____ Who? __________

    d. Friends _____

    e. Children _____

    f. Boyfriend _____ Girlfriend _____

    g. Other (please be specific) ________________________

 

22. Could you describe what you normally do each day, from the time you get up in the morning until you go to sleep at night?

 

 

23. Please describe the circumstances which contributed to you becoming homeless?

 

 

24. What are your greatest needs?

 

25. If there was a shelter in Harford County, instead of a motel room, a place where you could stay temporarily while looking for a permanent place to live, would you go there ? 

Yes _____ No _____

If yes, how long would you stay?

Up to 30 days _____ Up to 6 months _____ Up to one year _____

 

26. If the shelter, not a motel, had rules to follow and would require that you seek a job, get counseling if you needed it, pay part of your income to stay there, etc. would you still go to the shelter?

 

27. If you could get a shelter outside Harford County, would you go there?  Yes _____ No _____ Why? _________________________