Housing Program Initial Assessment

First name

Last name

Phone

Address

Are you homeless?

Do you have a vehicle?

What is your anticipated move in date?

Do you smoke Marijuana or Tobacco or both?

Are you currently employed? If so, where do you work and how long have you worked there?

Do you get SSI, SSDI, SSA or VA benefits? If so, how much do you get per month?

If employed, are you able to pay your $200 move in fee?

Do you have misdemeanors or felonies which prevent you from obtaining housing or employment?

Do you have a case worker? If so, what is their contact information?

Do you have family or an emergency contact in Summit County? If so, what is their contact information in case of an emergency?

Will you be residing alone? If not, who will be living with you and what's their age?

Are you able to pay for your housing program fee on the 1st of each month? If not, are you able to pay every 2 weeks if employed?

Do you have a substance abuse disorder? If so, are you currently in treatment?

Do you have a probation/parole officer? If so, in case of emergency, what is their contact information?

Do you have mental health issues? If so, please list your diagnosis and the medicine that you take.

Do you have any information that you feel the need to share with us?

Can you please send a text to 216-505-1282 with your name and let us know that you completed your initial assessment?

Date and time

Month

Day

Year

Time

HoursMinutes

We have amazing spacious rooms ranging from $700-$900/month with all utilities included and our homes are fully furnished. We specialize in rapid placements, so let us know once you are done with your initial assessment to expedite the process. We can be reached at 216-505-1282 or info@successfulfoundation.org.