Residential History on Program Entry

Program Entry Date:

Type of Residence:

Emergency shelter Transitional housing for homeless persons Permanent housing for Homeless Persons Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital(non-psychiatric) Jail, prison or Juvenile detention facility Room, apartment or house you rent Apartment or house you own Staying or living with family Staying or living with friend Hotel or motel paid for w/o emergency shelter voucher Foster care home Place not meant for habitation Other Don't know Refused

Length of Stay in Previous Place:
	One week or less
	More than one week, but less than one month
	One to three months
	More than Three Months, but less than one year
	One year or longer

Zip Code of last Permanent Residence:

	Full Zip Code Recorded
	Don't Know
	Refused