Prioritization List Application - Partners Ending Homelessness

Client Name

Date of Birth

Primary Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Sex

Woman

Man

Social Security Number

Last 4-digits only

Military Veteran

Yes

No

Current Location

Which emergency shelter is the client currently residing in?

What is the name of the non-profit organization paying for the client’s hotel/motel stay?

Date first entered the facility

From reading the above information and with the understanding that the client may not be eligible for CoC Housing, do you wish to continue?

Yes

No

EXIT APPLICATION

Where was the client residing immediately prior to entering the transitional housing facility?

Based on the information provided, this client does not meet the criteria for HUD homelessness. Please do not continue with this referral.

EXIT APPLICATION

Category 1: Literally Homeless – individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:

Has a primary nighttime residence that is a public or private place not meant for human habitation; or
Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, and local government programs); or
Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution.

Category 4 – Fleeing Domestic Violence

Any individual or family who:

Is fleeing, or is attempting to flee, domestic violence;
Has no other residence; and Lacks the resources or support networks to obtain other permanent housing.

Note: For the purposes of this binder, “Domestic Violence” includes dating violence, sexual assault, stalking, and other dangerous or life-threatening conditions that relate to violence against the individual or family member that either takes place in, or him or her afraid to return to, their primary nighttime residence (including human trafficking).