Housing Stability Assessment Form

Identifies past evictions, rent burden, utility arrears, and housing barriers for clients at risk of homelessness. Used by housing case managers during intake and reassessment to determine intervention needs and prioritize services.

Assessment Context

• Assessment Type
  Select the type of assessment being conducted.
• Assessment Date
• Case Manager Name
• Program / Project Name
• Referral Source
  How was this client referred to the program?
• HMIS Client ID (if applicable)
  Enter the client's HMIS unique identifier for HUD reporting purposes. Leave blank if not yet assigned.

Consent and Privacy Notice

• I have read and understand how my information will be used, and I consent to the collection and sharing of my information for housing services coordination.
• HMIS Release of Information
  Per HUD CoC Program regulations (24 CFR Part 578), clients must be informed of HMIS data practices.
• Client Signature
  By signing, you confirm your consent to the above terms.
• Date of Consent

Client Identifying Information

• First Name
• Last Name
• Date of Birth
  Required for program eligibility verification and HMIS reporting.
• Gender Identity
  Optional. Collected for HUD HMIS reporting (HUD Notice CPD-21-10).
• Race / Ethnicity
  Optional. Select all that apply. Collected for HUD HMIS equity reporting.
• Primary Language
  Used to arrange interpreter services if needed (ADA Title VI language access).
• Is an interpreter needed for this assessment?

Current Housing Situation

• Current Living Situation
• Current Address
  Enter current address if the client has a stable address. Leave blank if unsheltered.
• How long have you lived at your current address?
• Is the lease or rental agreement in the client's name?
• Is the client at imminent risk of losing housing within 14 days?
  Per HUD definition (24 CFR 576.2), 'imminent risk' means loss of housing within 14 days with no subsequent residence identified.
• How many nights has the client been homeless in the past 12 months?
  Required for chronic homelessness determination per HUD CoC regulations (24 CFR 578.3).

Rent Burden and Arrears

• Monthly Rent or Housing Cost ($)
  Enter total monthly rent or housing cost. Leave blank if unsheltered or in shelter.
• Total Monthly Gross Household Income ($)
  Combined gross income from all household members and all sources.
• Estimated Rent Burden
  Auto-calculated: monthly rent ÷ monthly gross income × 100. Values above 30% indicate rent burden; above 50% indicate severe rent burden.
• Does the client have past-due rent or housing arrears?
• Total Amount of Rent Arrears Owed ($)
• How many months of rent are past due?
• Has the client received emergency rental assistance in the past 12 months?
  Includes ERA1/ERA2 (Treasury), ERAP, or local emergency funds.

Utility Arrears and Energy Burden

• Are utilities included in rent?
• Does the client have past-due utility balances?
• Which utilities are past due? (Select all that apply)
• Total Estimated Utility Arrears ($)
• Has a utility shutoff notice been received?
• Has the client applied for LIHEAP or utility assistance this program year?

Eviction History

• Has the client been formally evicted in the past?
• How many formal evictions has the client experienced?
• Year of Most Recent Eviction
• Primary Reason for Most Recent Eviction
• Is there a current eviction court filing or unlawful detainer action?
  An active court filing may require immediate legal aid referral.
• Court Hearing Date (if known)
• Does the client need a referral to legal aid / tenant rights services?

Income and Benefits

• Current Income Sources (Select all that apply)
• Is the household currently enrolled in SNAP (food assistance)?
• Is the client currently enrolled in Medicaid / CHIP?
• Has the household experienced a significant income loss or change in the past 6 months?
• Reason for Income Change

Housing Barriers

• Housing Barriers Present (Select all that apply)
  Select all barriers that apply. This does not determine eligibility — it informs service planning.
• Which identification documents does the client currently have? (Select all that apply)
  Lack of ID is a common barrier to housing applications and benefit enrollment.
• Does the client require accessible housing features?
  Per ADA and Fair Housing Act, reasonable accommodations must be considered in housing placement.
• Describe Accessibility Needs
• Is there a current domestic violence, dating violence, sexual assault, or stalking safety concern?
  Clients with DV safety concerns may be eligible for confidential services and VAWA housing protections (42 U.S.C. § 14043e-11).
• Does the client need a referral to a DV advocate or safe housing resource?

Household Composition

• Total Number of People in Household (including client)
• Are there children under age 18 in the household?
• Number of Children Under 18
• Are any children in the household enrolled in school and potentially McKinney-Vento eligible?
  McKinney-Vento Homeless Assistance Act (42 U.S.C. § 11431) requires school liaisons be notified for homeless children.
• Are there household members who are elderly (62+) or have a disability?
• Is the client or any household member a U.S. military veteran?
  Veterans may be eligible for HUD-VASH vouchers or VA Supportive Services for Veteran Families (SSVF).

Risk Score and Case Manager Recommendation

• Overall Housing Stability Risk Level
  Case manager's holistic assessment based on all sections of this form.
• Recommended Interventions (Select all that apply)
• Service Plan Summary
  Document the individualized service plan developed with the client during this assessment.
• Scheduled Follow-Up Date
  Date for next contact or reassessment check-in.
• I certify that the information recorded in this assessment is accurate to the best of my knowledge and was gathered with the client's informed consent.
• Case Manager Signature