Designed Future Housing Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

THIS QUESTIONNAIRE MUST BE COMPLETED IN ORDER TO BE CONSIDERED FOR HOUSING. Be detailed, factual and raw with your responses. Don’t add a lot of details. Just list the facts. Your answers will remain confidential.

1. Your First and Last Name: *

2. Your Email Address: *

3. Your Phone Number: *

4. Emergency Contact Information *

Please list the name and phone number of someone we can contact in the event of an emergency.

5. Your Age: *

15-20

21-25

26-32

33-40

41-49

50-59

60-70

70 +

6. Sex: *

Male

Female

7. Race *

White

Black

Hispanic

Middle Eastern

Asian/Pacific Islander

Other

8. Do you have children? *

Yes

9. In what areas of life do you struggle? Which areas in life could use improvement? (CHECK ALL THAT APPLY.) *

Drug Addiction

Alcohol Addiction

Emotional Health/Mental Health/Overall Level of Happiness

Financial

Relationships

PTSD-Trauma

Physical Health and Well-Being

Self-Image/Self-Concept

Career/Job/Employment

Parenting

Other:

Required

10. Are you currently employed? *

Yes

11. If you're employed, what kind of job do you have? *

12. When was the last time you drank alcohol? *

Please provide the exact date.

13. When was the last time you used drugs of any kind? *

Please provide the exact date.

14. Income: *

Check All That Apply

No Income

On Public Assistance

Less than $20,000

$20,000-$34,999

$35,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000 or more

I rely on someone else's income (spouse, parent)

Required

15. What is your current housing situation? *

Currently renting an apartment.

Currently renting a home.

I own my home.

Living with family or friends.

Homeless

Living at a short-term facility/shelter

16. Do you have a Michigan Bridge Card *

Yes

17. Have you had interaction with any type of emergency services within the past year? *

I've had AT LEAST ONE interaction with police, ambulance or the fire department within the last 12 months.

I have had MORE THAN one interaction with police, ambulance or the fire department within the last 12 months.

I have had NO interactions with police, ambulance or the fire department within the last 12 months.

I have been arrested previously and spent time in jail or prison.

Required

18. Were you previously in jail or prison in the last year? If "Yes" please describe what you were charged with. *

Yes

Required

What crime were you charged with?

19. Do you currently have health insurance? *

Yes, I receive health insurance through a form of public assistance or Employer or pay for on my own..

No, I currently do NOT have health insurance.

Required

20. What is your current health condition? *

Check All That Apply:

I have no current health matters.

I have a health issue that requires daily medication.

I see a health professional on a regular basis.

I have a significant health issue but take NO medication.

I have been in the Emergency Room or hospital more than 3 times within the past year.

I have been in the Emergency Room or hospital 1-2 times with in the past year.

Required

21. Please list any medications you are currently taking. *

22. What is your height? *

23. What is your current weight? *

24. Do you currently smoke cigarettes? *

Yes

Has anyone ever told you that you snore loudly? *

Yes

25. If you currently smoke cigarettes, how many do you smoke on a daily basis?

1-5 cigarettes

1/2 pack of cigarettes

1 pack of cigarettes

1 1/2 packs of cigarettes

2 packs of cigarettes

More than 2 packs of cigarettes

3/4 pack of cigarettes

26. What are some of your current spiritual or religious beliefs? *

28. What is the status of your support system? These would include family and friends. (Check all that apply) *

I have satisfying relationships with many of my friends and family members.

I have strained relationships with several of my family members.

I have strained relationships with nearly all family members.

I don't have a relationship with any members of my family.

I have MORE THAN 3 close friends.

I have LESS THAN 3 close friends.

I don't have friends at this time.

Required

29. Which of the following statements are accurate or true about yourself? (CHECK ALL THAT APPLY.) *

I focus on my goals daily.

I focus on my goals whenever I think about it.

I don’t have a set of clear goals.

I tend to be very serious.

I’m happy and enthusiastic.

I have a great deal of stress in my life.

I love to play and have fun.

I tend to procrastinate.

My moods are up and down for the most part.

Sometimes I get very sad.

I feel depressed from time to time.

I resent other people who have it easier than me.

I can become angry or agitated easily.

Sometimes, I stay angry for days.

I wish other people could be more responsible.

I'm not happy at my current job, but I can't leave this job right now.

I need to be in a relationship to feel happy and content.

The decisions I make are typically good decisions.

I feel anxious sometimes.

I have difficulty concentrating.

I've been told I am stubborn.

I had a difficult childhood.

I had a good childhood.

I feel afraid at times.

I tend to worry about things.

I have difficulty sleeping or falling asleep.

Required

Please indicate the emotions you have felt within the past 2-3 weeks: *

Check all that apply.

Happiness

Fear

Joy

Worry or Concern

Doubt

Love

Gratitude

Anger

Grief

Shame

Remorse

Excitement

Depression

Anxiety

Compassion

Motivated

Required

That's it! You're finished! Simply click the "SUBMIT" button, and we'll be in touch!

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms