How many months 1 2 1 2 1 2 1 2 1 2 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ have you been 3 4 3 4 3 4 3 4 3 4 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ homeless in the past 5 6 5 6 5 6 5 6 5 6 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ three years? 7 8 7 8 7 8 7 8 7 8 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ [round up to the 9 10 9 10 9 10 9 10 9 10 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ nearest total 11 12 11 12 11 12 11 12 11 12 ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ⃝ ex. 1 day = 1 month; 35 More than 12 More than 12 More than 12 More than 12 More than 12 ⃝ ⃝ ⃝ ⃝ ⃝ days = 2 months] Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ What was the Loss of Job Loss of Job Loss of Job Loss of Job Loss of Job ⃝ ⃝ ⃝ ⃝ ⃝ primary of your Money Issues Money Issues Money Issues Money Issues Money Issues ⃝ ⃝ ⃝ ⃝ ⃝ homelessness? Loss of family member Loss of family member Loss of family member Loss of family member Loss of family member ⃝ ⃝ ⃝ ⃝ ⃝ Disability Disability Disability Disability Disability Please choose one, ⃝ ⃝ ⃝ ⃝ ⃝ Abuse/Violence Abuse/Violence Abuse/Violence Abuse/Violence you may read these ⃝ ⃝ ⃝ ⃝ ⃝ Kicked Out/Ran Away Kicked Out/Ran Away Kicked Out/Ran Away Kicked Out/Ran Away Kicked Out/Ran Away out loud ⃝ ⃝ ⃝ ⃝ ⃝ Aged Out of Foster Aged Out of Foster Aged Out of Foster Aged Out of Foster Aged Out of Foster ⃝ ⃝ ⃝ ⃝ ⃝ Care Care Care Care Care Time in Jail/Prison Time in Jail/Prison Time in Jail/Prison Time in Jail/Prison Time in Jail/Prison ⃝ ⃝ ⃝ ⃝ ⃝ Divorce Divorce Divorce Divorce Divorce ⃝ ⃝ ⃝ ⃝ ⃝ Other: Other: Other: Other: Other: ⃝ ⃝ ⃝ ⃝ ⃝ Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝
How many months have you been homeless in the past three years? [round up to the nearest total ex. 1 day = 1 month; 35 days = 2 months] ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5 ⃝ 6 ⃝ 7 ⃝ 8 ⃝ 9 ⃝ 10 ⃝ 11 ⃝ 12 ⃝ More than 12 ⃝ Doesn’t Know ⃝ Refused ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5 ⃝ 6 ⃝ 7 ⃝ 8 ⃝ 9 ⃝ 10 ⃝ 11 ⃝ 12 ⃝ More than 12 ⃝ Doesn’t Know ⃝ Refused ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5 ⃝ 6 ⃝ 7 ⃝ 8 ⃝ 9 ⃝ 10 ⃝ 11 ⃝ 12 ⃝ More than 12 ⃝ Doesn’t Know ⃝ Refused ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5 ⃝ 6 ⃝ 7 ⃝ 8 ⃝ 9 ⃝ 10 ⃝ 11 ⃝ 12 ⃝ More than 12 ⃝ Doesn’t Know ⃝ Refused ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5 ⃝ 6 ⃝ 7 ⃝ 8 ⃝ 9 ⃝ 10 ⃝ 11 ⃝ 12 ⃝ More than 12 ⃝ Doesn’t Know ⃝ Refused What was the primary of your homelessness? Please choose one, you may read these out loud ⃝ Loss of Job ⃝ Money Issues ⃝ Loss of family member ⃝ Disability ⃝ ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Loss of family member ⃝ Disability ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Loss of family member ⃝ Disability ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Loss of family member ⃝ Disability ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Loss of family member ⃝ Disability ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused