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Name(Required)

First Last

Phone

Alt. Phone

Email(Required)

Last Stable Address(Required)

Street Address Address Line 2 City State ZIP Code

Age

Gender(Required)

Race(Required)

Ethnicity(Required)

Marital Status(Required)

Partner's Name

Partner's Age

Partner's Gender

Partner's Race

Partner's Ethnicity

Best Time/Method to Contact(Required)

Where did you sleep last night?

If staying in a hotel, how long? Out date?

How did you learn about A Place to Stay?

Were you referred by an agency or organization?(Required)

Yes

What agency or organization?(Required)

Number of adults in household, including yourself

Name/Ages of other household adults not including self/partner

Please add each adult

Adult Name

Adult Age

Number of Children in Household

Name/Ages

Please add each child

Child Name

Child Age

The place I have been living is (where, how long)(Required)

Description and reasons/events leading to your current situation(Required)

Do you have a driver's license?(Required)

Yes

Do you have a state identification?(Required)

Yes

Do you own a vehicle or have reliable transportation?(Required)

Yes

If the car is not yours, how do you transport it?(Required)

Are you receiving any government assistance? (Food Stamps, etc.)(Required)

Yes

What type?(Required)

How much/date you receive?(Required)

For males 18 years and older, are you registered with selective service (Draft)?

Yes

If no, please visit https://www.sss.gov/register/

Are you a veteran?(Required)

Yes

Are you a military spouse?(Required)

Yes

To the navigate finding housing, please answer the following questions as honestly as possible; answers to these questions are not a condition of receiving services.

Number of "fur-babies" in your household:(Required)

How are they currently being cared for?(Required)

Do you have a disability?(Required)

Yes

What is your disability?(Required)

Do you receive any of the following?

SSI

SSID

None

How much SSI do you receive?(Required)

Date you receive SSI?(Required)

Month

Day

Year

How much SSID do you receive?(Required)

Date you receive SSID?(Required)

Month

Day

Year

Do you have a felony or misdemeanor charge?(Required)

Yes

What is the charge?(Required)

When did it occur?(Required)

Have you ever been evicted from a home?(Required)

Yes

When were you ecivted?(Required)

To assist in reparing credit or planning a budget, would you like a referral for financial literacy programming?(Required)

Yes

Employment

Completed High School(Required)

Yes

Higher Education?(Required)

Yes

Degree:(Required)

Have you had other vocational training?(Required)

Yes

Certifications:(Required)

Are you currently employed?(Required)

Yes

Where?(Required)

How many hours a week?(Required)

What is your income?(Required)

Are you paid:(Required)

Daily

Weekly

Biweekly

Monthly

Other

Do other members of your household have a source of income?(Required)

Yes

What is the source?(Required)

How much do they get paid?(Required)

Are they paid:(Required)

Daily

Weekly

Biweekly

Monthly

Other

Are you and/or other members of your household able to work?(Required)

Yes

Reason for no(Required)

What monthly expenses do you have and how much?(Required)

Add as many lines that apply

Expense

Amount in $

How have you been paying for the last six months?(Required)

What other organizations have you contacted?(Required)

How have they assisted?(Required)

If A Place to Stay is able to assist, what is your plan for meeting your own obligations in the future?(Required)

In a time of crisis or emergency, name two people on whom you can always lean on(Required)

Name

Why?

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A Place to Stay

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A Place to Stay is a United Way 501c3 Agency serving Blount County, Tennessee 84-3644615

A Place to Stay is a United Way 501c3 Agency serving Blount County, Tennessee 84-3644615