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Please complete the below assessment form if you are seeking homelessness prevention services and live within the following localities: Colonial Heights, Dinwiddie, Emporia, Hopewell, Petersburg, Prince George, South Chesterfield/Ettrick, Surry, Sussex, Wakefield, or Waverly.

For more information or to send documentation, please email Kristin Dibler, Prevention & Diversion Case Manager.

    Name

    Email

    Phone

    Are you a Veteran?

    Where did you stay last night?

    If you have a lease, how much is your monthly rent?

    If you are paying hotel expenses, how much are you paying?

    Is this the primary place you stay, or is there somewhere else you normally stay?

    If there is somewhere else you normally stay, please describe that place.

    Do you have to leave this place (or the place you normally stay)?

    If yes, what is causing you to leave?

    Have you tried asking for an extension on your rent payment or otherwise negotiating a way to stay in your current housing?

    If yes, what was the result of the conversation? If no, is this an option for you?

    Do you have a safe, appropriate place where you could live if you lose your current home?

    Approximately how much money would you need to pay immediately to keep your housing OR obtain other housing?

    Approximately how much money do you currently have available in savings, assets or other accounts?

    Do you have enough money to pay for your current housing costs, including any rent, hotel expenses or utility arrears?

    Have you received income in the last 3 months?

    Are you 18 years old or younger?

    Are you between the ages of 18-24?

    Are you single?

    Do you have a partner or spouse?

    Does your partner or spouse live with you?

    Do any children live with you?

    How many children under the age of 18 live with you?

    How many children over the age of 18 live with you?

    Is anyone in your household pregnant?

    Are you 55 years of age or older?

    Is your current housing jeopardizing another household’s housing stability?

    Have you ever experienced homelessness?

    If yes, have you experienced homelessness in the past 3 years?

    Does anyone in the household have a physical disability or chronic health condition?

    Does anyone in the household have a mental health or substance abuse issue?

    Have one or more members of your household had previous involvement with child welfare including foster care?

    Has the head of household "aged out" of foster care in the past 12 months?

    Has the head of household previously resided in an institutional setting (treatment facility, jail, prison, psychiatric hospital, etc.)?

    Is the head of household experiencing domestic violence?

    Does the head of household have one or more prior evictions?

    Does the head of household have arrears from a previous eviction (separate from current situation)?

    If you do have arrears/judgement(s), how much do you owe?

    Does the head of household have poor or no credit history?

    Does the head of household have more than one misdemeanor conviction?

    Does the head of household have a felony conviction within the past 10 years?

    Does the head of household have a felony conviction older than 10 years?

    Other notes (optional)

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