Heartland Coalition for the Homeless

First Name

Last Name

Middle Name

In what language do you feel best able to express yourself?

Date of Birth:

Age:

Social Security Number:

Consent to participate

Yes
No
Refuse

A. History of Housing and Homelessness

1. Where do you and your family sleep most frequently? Please check only one.

Shelter
Transitional Housing
Safe Haven
Outdoors

Other (Specify)

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2. How long has it been since you lived in a permanent stable housing?

3. In the last three years, how many times have you been homeless?

B. Risks

4. In the past six months, how many times have you:

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a) Received healthcare at an emergency department/room?

b) Taken an ambulance to the hospital?

c) Been hospitalized as an inpatient?

d) Used a crisis service, including sexual assault crisis, mental health crisis, family/intimate violence, distress centers and suicide prevention hotlines?

e) Talked to police because you witnessed a crime, were the victim of a crime, or the alleged perpetrator of a crime or because the police told you that you must move along?

f) Stayed one or more nights in a holding cell, jail, or prison, whether that was a short-term stay like the drunk tank, a longer stay for a more serious offense, or anything in between?

5. Have you been attacked or beaten up since you've become homeless?

6. Have you threatened to or tried to harm yourself or anyone else in the last year?

7. Do you have any legal stuff going on right now that may result in you being locked up, having to pay fines, or that make it more difficult to rent a place to live?

8. Does anybody force or trick you to do things that you do not want to do?

9. Do you ever do things that may be considered to be risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don't know, share a needle, or anything like that?

A. History of Housing and Homelessness

2. How long has it been since you lived in a permanent stable housing?

3. In the last three years, how many times have you been homeless?

B. Risks

4. In the past six months, how many times have you:

a) Received healthcare at an emergency department/room?

b) Taken an ambulance to the hospital?

c) Been hospitalized as an inpatient?

d) Used a crisis service, including sexual assault crisis, mental health crisis, family/intimate violence, distress centers and suicide prevention hotlines?

e) Talked to police because you witnessed a crime, were the victim of a crime, or the alleged perpetrator of a crime or because the police told you that you must move along?

f) Stayed one or more nights in a holding cell, jail, or prison, whether that was a short-term stay like the drunk tank, a longer stay for a more serious offense, or anything in between?

5. Have you been attacked or beaten up since you've become homeless?

6. Have you threatened to or tried to harm yourself or anyone else in the last year?

7. Do you have any legal stuff going on right now that may result in you being locked up, having to pay fines, or that make it more difficult to rent a place to live?

8. Does anybody force or trick you to do things that you do not want to do?

9. Do you ever do things that may be considered to be risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don't know, share a needle, or anything like that?

C. Socialization & Daily Functioning

10. Is there any person, past landlord, business, bookie, dealer, or government group like the IRS that thinks you owe them money?

11. Do you get any money from the government, a pension, an inheritance, working under the table, a regular job, or anything like that?

12. Do you have planned activities, other than just surviving, that makes you feel happy and fulfilled?

13. Are you currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other thinks like that?

14. Is your current homelessness in any way caused by a relationship that broke down, an unhealthy or abusive relationship, or because other family or friends caused you to become evicted?

D. Wellness

15. Have you ever had to leave an apartment, shelter program, or other place you were staying because of your physical health?

16. Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart?

17. If there was space available in a program that specifically assists people that lived with HIV or AIDS, would that be of interest to you?

18. Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you'd need help?

19. When you are sick or not feeling well, do you avoid getting medical help?

20. FOR FEMALE RESPONDENTS ONLY: Are you currently pregnant?

21. Has your drinking or drug use led you to being kicked out of an apartment or program where you were staying in the past?

22. Will drinking or drug use make it difficult for you to stay housed or afford your housing?

23. Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place where you were staying. because of:

a) A mental health issue or concern?

b) A past head injury?

c) A learning disability, developmental disability, or other impairment?

24. Do you have any mental health or brain issues that would make it hard for you to live independently because you'd need help?

25. Are there any medications that a doctor said you should be taking that, for whatever reason, that you are not taking?

26. Are there any medications like painkillers that you don't take the way the doctor prescribed or where you sell the medication?

27. YES or NO: Has your current period of homelessness been caused by an experience of emotional, physical, psychological, sexual, or other type of abuse, or by any other trauma you have experienced?