Interim Housing Application

AFTER filling out an application with our Program Coordinator, or at Community Action's Housing Resource Center (please ensure you've asked to be placed on AFC's wait list), please fill out this household assessment form. It will allow us to better serve your family by connecting you to available services prior to intake and after intake during case management. Please call Karen Yost, Program Coordinator, at 293-2993 ext. 0 on a weekly basis to update your application and to ensure we are aware you are still in need of services.






Household Information
Number of Adults in Household:
Number of Children in Household:
Is anyone in the household pregnant?:
Due Date:
All Household Members Legal Residents:

History of Homelessness
How long have you been homeless?
What is the city of your last permanent address?
Has anyone in your household lived outside of WA in last 3 years?
Has anyone in your household been homeless previously as an adult?
Has any adult in your household been homeless as a child?
How many times have you been homeless?:
In what year(s) were you homeless?:
What was your longest period of homelessness?

Current Living Situation
Please select "Yes" in the field next to the environment where you slept last night.

Place not meant for habitation:
Emergency shelter/Motel voucher:
Transitional housing:
Safe Haven:
Hospital (Non-psychiatric):
Psychiatric Hospital:
Substance abuse inpatient:
Jail, prison or juvenile detention:
Fleeing domestic violence:
Permanent housing:
Rental without subsidy:
Rental with VASH subsidy:
Rental with other non-VASH subsidy:
Staying with family:
Staying with friends:
Owned by client without subsidy:
Owned by client with subsidy:
Exiting foster care home or group home:
Hotel/motel paid for by client:
How long staying where slept last night?:
How long can you stay where you are?:

Which of the following reasons contributed to your homelessness?
Select "Yes" for each item that applies.

Alcoholism:
Displacement:
Domestic Violence:
Eviction:
Family Crisis:
Health Problems:
Illness:
Mental Health Issues:
Substance Abuse:
Economic/Financial Reasons:
Employment Issues:
Criminal History/Release from Jail:
Out of Home Youth:
Other Reason:

Criminal History
Does anyone in your household have any convictions or current/pending criminal court cases?
If so, please explain:

Rental History
Have you ever rented an aptartment or house?:
Have you ever received a pay-or-vacate notice?:
Have you ever received an eviction notice?:
Do you owe money to a previous landlord?:
If so, how much?:
Are you making payments?:
Have you ever received Housing Authority services:
When?:
Where?:
Have you ever been evicted from the Housing Authority?
Do you owe money to any Housing Authority?:
If So, how much?:
Are you making payments?:

Employment History
Is anyone in your household employed?
If so, what type of employment?
Hours worked last week:
Is anyone in your household looking for work?
Is anyone in your household looking to increase work hours?

Income Information
Please indicate the total monthly household income in the following categories. Do not use $ symbols, but do use the following format. NNNN.NN

Earned Income:
TANF Income:
SSI:
GA Income:
Child Support Income:
Social Security (Retirement) Income:
Workers Comp Income:
Unemployment Income:
Other Income Source:
Other Monthly Income:

Non-Cash Benefits
Which of the following non-cash benefits do your household receive?

Monthly Food Stamps Allotment:
WA Healthcare for Children:
VA Medical Services:
Medicaid:
Medicare:
Earned Income Tax Credit:
TANF Child Care Services:
TANF Transportation Services:
WIC:
Other TANF-Funded Services:
Section 8, Public Housing or Rent Assistance:

Medical / Mental Health / Substance Abuse History

Does anyone in your household have a developmental or physical disability?
If so, please explain the nature of the disability and any necessary accomodations:
Does anyone in your household have a chronic medical condition?
If so, please explain the nature of the medical condition and any necessary accomodations:
Does anyone in your household have a mental health condition?
If so, please explain the nature of the mental health condition and any necessary accomodations:
Is anyone in your household participating in mental health treatment?
Does anyone in your household have a history of substance abuse?
Is anyone in your household currently abusing substances?
What substances are currently being used, or have been used in the past?
What date were substances last used?
What substance was last used?
Is anyone in your household currently in a substance abuse treatment or sobriety program?
Was anyone in your household in a substance abuse treatment or sobriety program in the past?


Goals
What are your long term goals:
What activities are you currently doing toward your long term goals?
What activities would you do if accepted into a program at the Anacortes Family Center?

By clicking "Submit" below, I attest that I have completed this application to the best of my knowledge and understand that any false, incomplete or withheld information relating to this application may be grounds for denial of services or withdrawal/termination of services if discovered after enrollment in services.