Coordinated Assessment Coordinated Assessment Homeless Alliance for the Lower Shore (HALS) CoC "*" indicates required fields Agency Completing FormDate MM slash DD slash YYYY Name* First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY AgeRaceNumber of Household Members*Number of Minor Children*Do you have income?*Do you have income? Yes No Source*Amount*Frequency?*Frequency? Weekly Monthly Other Where did you stay last night?How long have you stayed there?When must you leave? MM slash DD slash YYYY Why do you want/need to leave?Are you receiving assistance from any agencies/organization(s)?*Are you receiving assistance from any agencies/organization(s)? Yes No Please list the agencies/organization(s) you receive assistance from.Please list the agencies/organization(s) you receive assistance from. Add RemoveDo you have health issues (physical, mental*, substance abuse) which require assistance?*Do you have health issues (physical, mental*, substance abuse) which require assistance? Yes No Please list the health issues (physical, mental*, substance abuse) which require assistance.Please list the health issues (physical, mental*, substance abuse) which require assistance. Add RemoveAre you or a member of your family a veteran?Are you or a member of your family a veteran? Yes No Are you experiencing or fleeing domestic violence?Are you experiencing or fleeing domestic violence? Yes No Do you need assistance to stay in your current housing?Do you need assistance to stay in your current housing? Yes No I need assistance finding alternate housing Are you willing to stay in a shelter?Are you willing to stay in a shelter? Yes No Additional Notes or CommentsNameThis field is for validation purposes and should be left unchanged. Δ
