Homeless Prevention Program - Initial Assessment

Date

Client Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Zip Code

Have you been in your residence for 90 days?

Plano Resident

Notice to Vacate

Have you used this program in the last three years?

Do you receive Section 8?

Is the lease in your name?

Do you owe back rent?

⚠️ Please Note If you owe back rent, you will not qualify for this program. We will provide a referral to another agency that may or may not be able to assist you with past-due rent.

How many are in your household?

What is the current crisis you are dealing with? (This is the reason you are unable to pay your rent)

How many are children under 18 years old?

What is the amount of your rent?

How many bedrooms?

Are you currently employed?

What is your gross income (income before taxes)?

Is that,

What other Income Resources do you have?

Result

If you qualify you will be able to submit, if there is no Submit button you did not qualify for the next step. Please wait for the case manager to call you and schedule an appointment and speak to you more in depth about your situation. Make sure you are in the following zipcodes: 75074,75023,75024,75025,75075,75093,75094

Homeless Prevention Program - Initial Intake Assessment

Assess the Following