Safe Harbor Transitional Housing

Client Name *

Date:

Telephone - Home: *

Second phone number:

Email address: *

Client address: *

County * County

Disasters Affected *

2015 Floods

2016 Floods

Hurricane Harvey

Did you relocate after the storm?

Yes

No

Total number of people in household: Total number of people in household:

Household demographics

Other assistance received:

Are you currently working with another agency who is providing case management? *

Yes

No

Provide the name of the agency who is providing you with case management: *

Describe the nature of assistance client is seeking: *

Briefly describe your current disaster situation: *

Describe how a three-month stay in an apartment will aide you in your Hurricane Harvey disaster recovery: *

Safe Harbor Application Form