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About us
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Get Involved
Our Blog
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Sponsor a Room
Endowments
Appreciated Assets
Sponsor an Event
Sponsors and Partners
Contact us
Menu
About us
Staff and Board
News & Events
Services
Get Involved
Our Blog
Become A Volunteer
Sponsor a Room
Endowments
Appreciated Assets
Sponsor an Event
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Apply for Shelter
Transformation Starts Here.
First Name
Middle Name
Last Name
What is your email address ?
What is the best phone number to reach you?
What is your date of birth?
Personal Information
Are you Pregnant?
Yes
No
Not Sure
Do you have children?
Yes
No
How many children do you have?
Are you homeless?
Yes
No
Briefly explain your situation:
Im in Harris county ?
Yes
No
For how long?
Where did you sleep last night?
What county?
For how long?
Where did you sleep last night?
Have you ever lived in a shelter?
Yes
No
City/County/State
Length of stay?
Are you currently employed?
Yes
No
Where are you employed?
How long have you been employed?
Who is your previous employer?
How long were you employed?
Highest level of education
Some High School
High School Graduate or Equivalent
Occupational, technical or vocational program
Some College
College Degree
What is your monthly income?
SSI, SSDI
Food Stamps
Other Income?
Yes
No
What and how much?
Do you have Texas identification?
Yes
No
Do you own a car?
Yes
No
Is your car registered?
Yes
No
Identifying Documents
Do you have your birth certificate?
Yes
No
Do you have a social security card?
Yes
No
Have you ever been arrested?
Yes
No
What County and State?
Charges
Convicted?
Yes
No
Are you working with an attorney for this or any other situation?
Have you had an eviction?
Yes
No
Please explain:
Can you pass a drug test today?
yes
no
Are you taking any medications?
yes
no
Please explain:
Are you a victim of domestic violence?
yes
no
For how long?
Is your abuser actively seeking you?
yes
no
Is there a case against your abuser
Have you been around anyone who has any of the following symptoms in the last 14 days: Sore throat, cough, chills, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100°F?
yes
no
Have you or anyone in your household traveled in/out of the US in the past 21 days?
yes
no
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
yes
no
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
yes
no
Signature
Enter your full name below:
All information is confidential.
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