Appendix_5_HSE_Needs_and_Preferences_Assessment 1.docx

Appendix 5 Appendix 5

Housing Search Needs and Preferences Assessment

Note on Form Purpose and Use This form is used by a qualified Housing Search Entity during an initial interview with a Program Participant. The form assesses housing specific preferences and needs as well as potential barriers to housing access. This information will be used by the Housing Search Entity to help plan a housing search. A copy will be provided to the Program Participant and their Case Manager, as appropriate.

Participant Name:

Address:

Date:

Housing Search Entity:

Setting Neighborhood Type Preferences |_| Urban |_| Suburban |_| Rural Town Preference and/or Zip Code 1st Choice:

2nd Choice:

3rd Choice:

Location Public Transportation Preferences On specific bus route(s):

On specific subway/train route:

Use Paratransit (i.e. The Ride):

Walk to Preferences |_|Grocery/Food Store |_|Laundry |_|Health Clinic |_|Pharmacy |_|Bank |_|Other Unit Size |_| Single Room Occupancy (own room but shares bathroom & other facilities) |_| Efficiency Unit |_| 1 Bedroom |_| 2 Bedrooms |_| 2+ Bedrooms |_| Live-in Aide |_| Live with Child(ren) |_| Live with Other |_| Other Type of Housing |_| Small scale multi-family |_| Large apartment complex |_| Housing with on-site services (such as meals, VNA on-site) |_| Open to all housing types

Floor of Unit |_| Ground floor |_| Higher floor |_| No preference Accessibility Features Needed |_| Elevator |_| Design for wheelchair use |_| Features for low-vision or blind |_| Features for Auditory Needs (speaking or loud alarms, flashing smoke detectors and doorbells) |_| Automatic door open or electronic key cards |_| Roll-in shower |_| Other Amenities |_| Laundry in Building |_| Pets Allowed |_| Off-street Parking |_| Bath/Shower |_| Shower Only |_| Building Security on Site |_| Air Conditioning |_| Other Landlord/Property Manager on Site |_| Yes |_| No Setting Provides Meals |_| Yes |_| No Setting Provides Planned Activities |_| Yes |_| No Barriers to Housing Access |_| Any criminal history (will appear on Criminal Offense Record Inquiry) |_| Any outstanding court involvement issue such as warrant or unresolved court appointment |_| Eviction in history (will appear on credit report) |_| Housing court involvement |_| Past due accounts with utilities (will appear on credit report) |_| No experience as lease holder for rental housing.

|_| No ability to document any rental history |_| Poor credit history (will appear on credit report) |_| Requires 3 or more bedrooms |_| History of destruction of property |_| Significant need for tenancy readiness coaching and supports

Housing History |_| Has history of name on rental lease.

|_| Has documentation to prove rental history (old leases, landlord contacts, |_| Has documentation to prove past residency in community of interest today.

Long Term Waiting List Applications Interest |_| Yes – apply to long term waiting lists to open options in the future |_| No – only focus on the immediate need for housing

Top Priorities When finding housing, it is not usually possible for all preferences to be met. The ideal setting is a match between available options and the most critical priorities. Below, identify the top three priorities. For example, 1) my own place, can be an efficiency or one bedroom; 2) need to live in either Malden or Revere area so I am near family; and 3) grocery store has to be within “walking” distance.

1) 2) 3) Comments and Notes

Revised 4/2023