Social Services for the Homeless (SSH) is provided to those with other sources of income such as employment, child support, SSD etc. The funding is used to help families and individuals avert homelessness by providing short term non-recurring back rent, security deposit and utility assistance for those who have a demonstrated need. Families and individuals seeking SSH funding must apply and be found ineligible for other public assistance programs such as TANF/GA/SSI.

Applicant Information

Gender: (select one) *

Race (select all that apply) *

Please select all that apply.

Monthly Income Sources:

SNAP (Food Stamps)	Special Supplemental Nutrition Program for Women, Infants, & Children (WIC)
TANF Child Care services	TANF transportation services
Other TANF-funded services	Section 8, public housing, or other ongoing rental assistance
Temporary Rental Assistance	Other Source Other Source

Yes	No
Client Refused	Data Not Collected

Male	Trans Male F to M	Gender Non-Conforming (i.e not exclusively Male of Female)
Female	Trans Female M to F	Client Refused

American Indian/Alaskan Native	White	Native Hawaiian/Pacific Islander
Black/African American	Asian	Client Refused

Individual Male	Two Parent Family – Adult	Individual Female
Two Parent Family – Youth	Individual Male Youth (<18)	Adult Couple w/o Children
Individual Female Youth (<18)	Household w/only Children	Single Parent Family – Male Head
Other household type	Single Parent Family – Female Head	Household member - adult
Single Parent Family – Youth Head	Household member – child

Benefits Loss/Reduction	Injury	Job Income Loss/Reduction
Domestic Violence	Eviction	Asked to leave shared residence
Relocation	Drug/Alcohol Abuse	Release from prison/jail
Other	Release from Hospital	Natural Disaster
Release from Psych. Facility	Foreclosure – Rented Property	Illness
Foreclosure – Owned Property	Unknown	Not Homeless

Social Services for the Homeless

Applicant Information

Income Sources

Monthly Income Sources:

Non-Cash Benefits:

Household Composition

Non-HMIS Data Elements

Additional Applicant information

English	Spanish	French	Chinese	Arabic	Hebrew	Russian	Sign Language
Creole	Greek	Italian	Japanese	Vietnamese	Braille	Other

Did not attend school	1st grade	2nd grade	3rd grade
4th grade	5th grade	6th grade	7th grade
8th grade	Some high school	Graduated high school

None	Associates Degree
Bachelors	Masters
Doctorate	Other graduate/professional degree
Certificate of advanced training or skilled artisan

Shelter/Housing	Drug Treatment	Mental Health Care	Medical Care
Legal Aid – CRSJ/Civil	Legal Aid – Immigration	Financial Assistance – Utilities	Financial Assistance – Housing
Financial Assistance – Moving Expense	Financial Assistance – Other	Other