* 1. Gender

* 2. Age

* 3. How many people in your household including yourself?

  None 1 2 3 4 5 6 or more
Adults
Children

* 4. Where did you stay last night?

* 6. Employment

* 7. Do you receive any of the following?

* 8. Was domestic and/or substance abuse a factor in your becoming homeless?

  Yes No
Domestic Abuse
Substance Abuse

* 9. Do you have transportation?

* 10. Additional Information

T