Friendship House
A Sanctuary In Time Of Need
302-652-8278 • fax: 302-652-8641

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| 1. Do I know my way around the
city? If "no", am I just passing through? |
Yes No Yes No |
| 2. Am I alone? If "no", is my spouse and/or children with me? |
Yes No Yes No |
| 3. Does a family member know where I am? | Yes No |
| 4. Do I have somewhere to stay for the next seven nights? | Yes No |
| 5. Do I have money and/or food stamps to provide meals for myself? If "no", do I have a place to store and prepare food? |
Yes No Yes No |
| 6. Do I have adequate clothing to protect me from the weather? | Yes No |
| 7. Do I have a secure place to store my most important belongings? | Yes No |
| 8. Do I have the means to keep my clothing and myself clean? | Yes No |
| 9. Do I have personal I.D.? Does it include a valid driver’s license? Does it include a social security card? Does it include a birth certificate? |
Yes No Yes No Yes No Yes No |
| 10. Do I have a local mailing address? | Yes No |
| 11. Do I have a phone where I can make and receive calls? | Yes No |
| 12. Do I have a medical condition that needs attention? If "yes", have I seen a doctor? Should I be on medication? |
Yes No Yes No Yes No |
| 13. Do I have reliable transportation? | Yes No |
14. Am I able to work? |
Yes No |
| 15. Do I have a regular source of income? If "yes", is it adequate for my basic needs? Am I expecting it soon? |
Yes No Yes No Yes No |
| 16. Do I use alcohol, drugs or tobacco? | Yes No |
| 17. Do I need someone to talk to? | Yes No |
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