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Emergency Housing Application

First Name *

Last Name *

Phone *

Email *

What is your date of birth? *

What is your biological gender? *

Female
Male
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What is your ethnicity? *

African American

Asian

Caucasian

Hispanic

Latino

Native American

Other

What is your religious preference? (this does not disqualify anyone, just for informational purposes) *

What is your current location (city and state)? *

Do you have your Driver's License, Social Security Card, birth certificate or a state ID? (please mark all that apply) *

Driver's License

Social Security Card

Birth certificate

State ID

None of the above

Do you currently have medical insurance? *

Yes

Do you have transportation to the Pittsburgh location? *

Yes

Describe your current situation. *

Have you been in any programs before? *

Yes

Are you currently in a program? *

Yes

Have you ever performed sexual favors for money, rent, drugs, food, or protection? *

Yes

Have you ever engaged in prostitution or other sex acts and couldn’t leave? *

Yes

Have you ever engaged in sex acts for the financial benefit or political favor of someone else? *

Yes

Any current or ongoing medical issues? *

Yes

Have you been hospitalized within the past 6 months for mental health needs? *

Yes

Do you have a current mental health diagnosis? *

Yes

Are you currently on any medication? *

Yes

Do you have any mobility issues? *

Yes

Alcohol or substance use history? *

Yes

Any current legal involvement? *

Yes

Any active warrants? *

Yes

Any additional comments?

LET'S DRIVE CHANGE

A small step can change lots of lives

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$100M

Every plate makes a new beginning.

Her Safe Haven is a 501(c)3 - all donations are tax-deductible

[email protected]

412-567-1727 (24/7 Line)