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CERA Screening
Hi my name is _____. I work with the supportive services department at LCBH. I’m calling to ask you a few questions to see if you qualify for our Court-Based Emergency Rental Assistance Program. Do you have a few minutes to talk? Before we begin, I want you to know that as a social worker, I am a mandated reporter. What this means is that everything we discuss is confidential with the exception of child abuse, elder abuse, abuse of disabled adults, and/or bodily harm to yourself or others, which I may be required to report. Are you still comfortable talking with me?
Name
First
Last
Date of Birth
Month
Day
Year
Phone
Email
Address
Street Address
Address Line 2
City
Alabama
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American Samoa
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Delaware
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Armed Forces Americas
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State
ZIP Code
Eligibility Questions
Chicago resident?
Yes
No
Have you received funding from 311/State Homelessness Prevention in the last 24 months?
Yes
No
Have you received an eviction notice?
Yes
No
What kind of eviction notice?
5 Day
10 Day
30 Day
Reason for the notice?
Non-payment, lockout, foreclosure
Do you have an upcoming court date?
Yes
No
When is your court date?
Month
Day
Year
Finances
What is your primary source of income?
Do not include benefits here.
How much does your primary source of income bring in every MONTH?
Do you receive any of the following benefits?
SNAP
LIHEAP
TANF
Veteran's Benefits
Other
How much do you receive from SNAP each month?
How much do you receive from LIHEAP each month?
How much do you receive from TANF each month?
How much do you receive from Veteran's Benefits each month?
How much do you receive from Other each month?
What is your monthly rent?
Do you have a housing subsidy?
Yes
No
How much is your housing subsidy per month?
Do you owe any back rent?
Yes
No
How much back rent do you owe?
For how many months do you owe back rent?
Crisis
Are you experiencing a temporary economic crisis?
Yes
No
Are you experiencing a temporary economic crisis? If so, does it fall into one of the following categories?
Loss of employment
Medical disability/emergency
Natural disaster
Loss/delay of some form of public benefit
Substantial change in household composition (ie: pregnancy or loss of financial provider)
Illegal action by landlord
Victimization by criminal activity
Displaced by government or private action
Other
Case Assessment Questions
If given the option, are you looking to move or stay in your current location?
Move
Stay
How many people live in your household?
How old are they?
Are you up to date on all utility payments?
Yes
No
How much/who do you owe?
Do you currently have legal representation?
Yes
No
Who represents you?
In the event you are eligible to receive our services, do you consent to LCBH contacting your landlord or rental agency on your behalf?
Yes
No
Landlord/Rental Agency Name
Landlord Phone
Landlord Email
How is your relationship with your landlord?
Great
Good
Fair
Poor
Terrible
Emergency Contact
Emergency Contact Name
First
Last
Emergency Contact Phone
Referral Source