211 Orange County | Now that's Progressive 211 Orange County

Gender *

Female

Male

Trans Female (MTF or Male to Female)

Trans Male (FTM or Female to Male)

Gender Non-Conforming (i.e. not exclusively male or female)

Do not know

Refuse to answer

Race

White

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

Do not know

Refuse to answer

Ethnicity *

Non-Hispanic

Hispanic

Do not know

Refuse to answer

Birthday *

Do not know

Refuse to answer

Veteran Status *

Yes

No

Do not know

Refuse to answer

How many months behind on rent? *

Monthly rent *

Have you filed a declaration of COVID-19 related financial stress? *

Yes

No

Have you received an eviction notice? *

Yes

No

Date on the eviction notice received *

Is your situation due to COVID? *

Yes

No

Current monthly income: *

Have you moved because of economic factors 2 or more times in the last 60 days *

Yes

No

Household with dependent children 0 to 17 *

Yes

No

Household with currently pregnant woman *

Yes

No

History of homelessness as an adult *

Yes

No

Housing will be lost within 14 days *

Yes

No

Housing will be lost within 21 days *

Yes

No

Domestic violence or abuse in household *

Yes

No

Household with a senior, 65 years or older *

Yes

No

Household with an individual convicted of a felony *

Yes

No

Someone in the household has a mental or physical disability and/or circumstances that affect housing *

Yes

No

History of previous evictions *

Yes

No

Have you been out of work for 3+ months? *

Yes

No

Sudden and significant loss of income *

Yes

No

Applied for shelter and spent at least one night during the prior 60 days literally homeless *

Yes

No

Rental and/or utility arrears *

Yes

No

Mobile Phone *

Other Phone

Email

Address *

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