HOMELESS SURVEY

HOMELESS SURVEY

What is your gender

Male
Female

What is your age

  Under 18 years of age
  18 - 24
  25 - 30
  31 - 37

  38 - 45
  46 - 52
  53 - 59
  60 and over

What month were you born

  Jan
  Feb
  Mar
  Apr
  May
  June

  July
  Aug
  Sept
  Oct
  Nov
  Dec

Have you served in the Military

Yes
No

Are you currently working

Yes
No

Do you have a current ID or Drivers License

Yes
No

What was the last State you considered your residence

What is the reason you are in New Orleans

Which catogery best describes your racial background

  American Indian
  Asian
  Black
  Hispanic
  White
  Other

Are you a (check only one response)

  Single Person
  Single parent with children under 18
  Couple with children under 18
  Couple without children
  Grandmother
  Grandmother with Grand Children

Do you have a permanent place to live

Yes
No

Including now, what is the total number of times you have been without a permanent place to live in the past three years

  1 - 3 times
  4 - 6 times
  7 - 9 times
  Over 10 times

As a child or youth, were you ever in foster care or another type of out-of-home placement

Yes
No

Do you think you have or have been told you have

  Serious Mental Illness
  Serious medical or physical condition
  Alcohol or drug abuse
  Developmental disability
  Hiv/Aids

Are you or anyone else in your family receving ANY of the following Government Benefits

  Food Stamps
  Welfare
  Social Security Income

Why did you become homeless

  Hurricane Katrina
  Afforable Housing
  Fema Benefits expired
  Mayor ask me to come home

  Homeless before the storm
  Homeless in another state
  Other

If you have another reason why you are homeless