Housing Needs Survey

Question Title

* 1. What type of housing are you seeking?

Temporary

Permanent

Question Title

* 2. Are you over 18 years old?

Yes

No

Question Title

* 3. Are you diagnosed with a mental illness?

Yes

No

Question Title

* 4. When do you need housing?

immediately

3-6 months

6-12 months

Question Title

* 5. What is your income from all sources?

$0-$20,000

$20,000-$50,000

$50,000-$100,000

Over $100,000

Question Title

* 6. Contact information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number