CT Targeted Prevention for Homelessness – United Way of Connecticut

iCarol call report number

Household Type*

Households without children
Households with at least one adult and one child
Did not to say

Zip Code*

Gender

Ethnicity

Race

Age

Please enter a number from 0 to 100.

Current Living Situation*

Rent apartment or home (name on lease)
Live in shared housing (name not on lease)
Did not to say

Risk to Current Living Situation/Why have you decided to ask for help?*

Received Notice to Quit & in Court Process
Received Notice to Quit
Rent is in Arrears
Did not Say

Percentage of Area Median Income (AMI)

Please enter a number greater than or equal to 0.

If you rent your apartment or home, is it public housing or subsidized affordable housing?*

Scoring

1. Household with at least one dependent child under age 6 in physical custody?*

2. Household with 3 or more minor children in physical custody?*

3. Current household income is $0 (i.e. not employed, not receiving cash benefits, no other current income)?*

4. Annual Household Gross Income Amount*

5. Sudden and significant decrease cash income (employment and/or cash benefits) AND/OR unavoidable increase in non-discretionary expenses (e.g. rent or medical expenses) in the past 6 months for the household?*

6. Major change in household composition (e.g. death of family member, separation/divorce from adult partner, pregnancy or birth of new child) in the past 12 months?*

7. Rental evictions within the past 7 years for any adult in the household?*

8. Has the head of houshold ever had any involvement in child protective services? (investigation, protective care, an open case, or a child in foster care)*

9. Has head of household ever experienced literal homelessness (in a shelter, transitional housing, in a vehicle, on the streets, or fleeing from domestic violence)?*

10. Has head of household been literally homeless more than one time?*

11. Has head of household been literally homeless in the last year?*

12. Any adult in the household with disabling condition (physical health, mental health, substance use) that directly affects ability to secure/maintain housing?*

13. If children live in the houshold, does any child have a disabling condition (physical health, emotional disturbance, substance use) that directly affects ability to secure/maintain housing?*

14. Any adult in household with a criminal record for arson, drug dealing or manufacture, or felony offense against persons or property?*

15. Any adult in the household a registered sex offender?*

Total Score