Permanent Supportive Housing Pre-Screening Form

If you currently reside in Multnomah County, are chronically homeless, and suffer from a disabling condition, please complete the form below.

Someone from our Coordinated Housing Access Team will follow up with you if you meet the full eligibility criteria.

NOTE: Completing this form does not automatically qualify you for permanent supportive housing.

Name

First Name

Last Name

Phone Number

(###)

###

####

Gender

Race

Ethnicity

Date of Birth

YYYY

In what county are you seeking services?

Where you're staying or where we can find you?

Specify all sources of income for yourself as well as each member of your household.

Current housing situation

How long have you been homeless?

How many times have you been homeless over the last three years?

Do you consider yourself to be disabled?

How many people are in your household?

Are there any minors (under the age of 18) in your household?

Is there any other information you think we should know?

Are you interested in Culturally Specific Services provided by