"*" indicates required fields Project Name* Unique IdentifierThis optional field is only used to distinguish submissions. Do not use name, SSN, or other PII. HiddenAgeOn what date did your current episode of homelessness begin? Month Day Year How many times have you/your household been on the streets or in an emergency shelter in the past three years?–Select–One Episode or First Time HomelessTwo EpisodesThree EpisodesFour or More EpisodesWhat is the total number of months you/your household have experienced homelessness on the street or in an emergency shelter the past 3 years–Select–1 Month or less2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months12 MonthsMore than 12 MonthsDo you have any long term disabling conditions?*–Select–YesNoOther / Don't Know / RefuseWhich conditions do you have? Alcohol Abuse Substance Abuse Chronic Health Condition Developmental HIV / AIDS Mental Health Problem Physical Disability Have you ever been a victim/ survivor of domestic violence, dating violence, sexual assault, sex trafficking, or stalking?*–Select–YesNoOther / Don't Know / RefuseWhen did the experience occur?–Select–3 Months Ago or Less3 to 6 Months Ago6 Months to 1 Year Ago1 Year or More AgoOther / Don't Know / RefuseAre you currently fleeing?–Select–YesNoOther / Don't Know / RefuseDemographic InformationHave you served in the US Armed Forces (including Reserves called to active duty)?*–Select–Not a VeteranVeteranDon't Know / RefuseWhat gender do you identify with?*FemaleMaleNon-BinaryTransgenderQuestioningDon't Know / RefuseWhat ethnicity do you identify as?*–Select–Non-Hispanic / Non-Latino(a)(o)(x)Hispanic/Latin(a)(o)(x)Other / Don't Know / RefuseWhat race(s) do you identify as?Primary Race*–Select–American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther / Don't Know / RefuseSecondary Race–Optional–American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther / Don't Know / RefuseWhat is your date of birth?*Do not enter actual date of birth. Just enter the year so that approximate age can be calculated with 01 and 01 as Month and Day.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Additional Household MembersPlease add all other members of your household that are currently experiencing a housing crisis. Unique ID What is your relationship to the Head of Household? Age What gender(s) do you identify with? Actions Edit Delete There are no Household Members. Add Household Member Maximum number of household members reached. HiddenTotal Household Members