Online Assessment Date* Time* : HH MM AM PM Contact InformationName* First Last Phone Number*Alternate Phone NumberEmail I am taking this assessment:*OnlineOver the phoneAs a walk inI am taking this assessment:*By myselfWith AutumnWith CaitlinWith JenniferWith HillaryWith DeniseWith SabrinaWith RosieWith an InternOtherWhat county are you currently residing in?*Collin CountyDallas CountyTarrant CountyOtherDo you have a child under the age of 18 in your full time custody or care?*YesNoOther ResourcesFamily Gateway's services are for those who have a child under the age of 18 in their full time care AND currently reside in Dallas or Collin County. If you do not have custody of a child under the age of 18, please call the Bridge Homeless Recovery Center at (214) 670-1101. If you do not reside in Dallas or Collin County, please call 211 for services in your area.IntroductionTo determine what services may be available for you, we will need to collect some basic information about your current situation. This information is confidential and will only be used to assist you in accessing appropriate resources. You may refuse to answer any questions, but doing so may mean you will not be referred to available resources that might best help you in your current situation.Do we have your permission to collect this information?*YesNoDo we have your permission to make a referral on your behalf to agencies that may be able to assist you?*YesNoDo we have your permission to enter the information you provide into HMIS and share it with other agencies that may be providing you with assistance?*YesNoAre you homeless (living on the street, staying in a shelter, fleeing domestic violence) or at-risk of homelessness?*YesNoAre you currently residing with, or trying to leave, an intimate partner who threatens you or makes you fearful?*YesNoWhere did you sleep last night?*What brought on your housing crisis?* Problems with landlord Rental or utility arrears Victim of foreclosure or rental property Unable to pay rent Violence or abuse occurring in the family's household Evicted or in the process of being evicted from a private dwelling or housing provided by family or friends Living in housing that has been condemned Experiencing overcrowding Other Has your household experienced homelessness in the last 12 months?*YesNoHave you ever stayed at a shelter or received other homeless services before?*YesNoWhat is the name of the agency, and when were you last there?Are you safe in your current living situation?*YesNoWhat makes the location unsafe?Is there anyone else you and your family could stay with for at least the next three (3) to seven (7) days if you were able to receive limited services (i.e. case management, transportation services, food pantry, limited financial support, other referrals)?*YesNoWhat would you need to help you stay where you stayed last night again?* Landlord mediation Conflict resolution Rental assistance Utility assistance Other financial assistance Other assistance Would it help if we contact the person you stayed with?*YesNoWhat is the name of that person? First Last What is the best way to contact him/her (i.e. phone, email)?Do you believe you will become homeless within the next seven (7) days?*YesNoIf you are currently housed, what type of assistance would you need to stay there? Select all that apply.* Food assistance Rental assistance Utility assistance Tenant/landlord mediation CommentsThis field is for validation purposes and should be left unchanged.