Health Care Without Walls Referral Form

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The survey will take approximately 8 minutes to complete. Please complete the questions below to submit a referral for services for homeless and housing-insecure women and women identified adults. A Health Care Without Walls staff member will follow up with you and your client within two business days.

Name *

Social Security Number *

Email *

Address *

Phone number

Client DOB *

YYYY

Client preferred language *

Interpreter needed

Yes

Clear selection

Housing status *

Housed

Homeless

If Housing insecure
*

Homeless/shelter

Couch Surfing

Unsafe Living conditions

At Risk of Homelessness (overcrowded , eviction, rental arrears)

CSPECH Referrals

Chronically Homeless ( at least 12 months of homelessness within the past 3 years)

Behavioral Health Diagnosis (mental health or substance use disorder )

Housing Pathway ( housing voucher, selected from waiting list)

Clear selection

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