Are you currently living...
In a place not meant for habitation - car, park, abandoned building, or on the street?
 
In an emergency shelter - rescue mission, Salvation Army, etc?
 
 
In transitional or supportive homeless shelter/ housing program?
 
 
In a hospital or institution (including prison)?
 
 
About to be evicted or terminated from your lease RIGHT NOW (within 7 days), and you have no other housing alternatives?
 
 
In a substance abuse facility, or mental health facility, from which you are ABOUT TO BE DISCHARGED (within 7 days), and you have no support network and no resources to find any type of housing situation?
 
 
Leaving a domestic violence housing situation and you do not have a support network or any other housing alternatives?
 
 
Condemned housing - substandard housing that prohibits occupancy?
 
 
Other information
Are you a Wake County resident or do you currently work in Wake County?
 
 
Do you have any pending felony convictions, or are you awaiting trial for a felony charge?
 
 
Do you have dependent children under age 18 currently living with you?
 
 
Are you currently working full-time, or do you have a recent (within past 6 months) work history?
 
 
Have you been diagnosed with any mental health condition?
 
 
If yes, are you currently being treated by a physician for this condition?
 
 
If you've been diagnosed as alcohol or substance dependent, how long have you been clean and sober?
Days  
Months  
Years  

Are you currently clean an sober now?
 
Your contact information
First Name
 
Last Name
 
Mobile or daytime phone
 
Home or evening phone
Other phone
Your e-mail address