Coordinated Entry System & COVID-19 Risk Assessment Form
For people experiencing homelessness or at risk of homelessness in Central Oregon: this form lets the HLC know that you are seeking support. This is a new system, and we appreciate you bearing with us while we try to connect people with housing and other resources.
Only the first few questions are required, but answering more will help us get you connected.
Your Date of Birth
Which city or area do you spend the majority of your time?
Crooked River Ranch
Where do you/your family sleep most frequently?
Shelter (for example, Bethlehem Inn)
Transitional Housing (for example, Nancy's House, Grandma's House, Shepherds House, LOFT resident)
Outdoors (for example, tent camping on public land)
In a vehicle (including an RV or trailer without hookups)
Staying with friends or family (for example, couch surfing or doubled up)
In a structure not meant for habitation (for example, a shed or abandoned building)
Not homeless today, but probably will be soon.
How long has it been since you felt like your housing was safe and stable?
Two parent household
Couple, no children
How many adults (age 18 and up) are in your household?
1 (Just me)
None - I am under 18
How many children (below age 18) are in your household?
Did you or a member of your household serve in the U.S. military?
It's important to be able to reach you if there are resources available!
We know that phones get turned off and numbers change, so please share some options on how to reach you. Come back to update this form if needed.
Phone number (if is safe to receive calls from a service provider). And email address (if you check email).
If we can’t reach you by phone/email, who can we call that will know where you are or how to reach you? Please give us their name & phone number or email. This could be a good friend, family member, probation officer, or case manager.
(Optional) Any notes to share?
How do you identify your race?
Are you Latino or Hispanic?
Do you or another adult in the household have a disability? (including physical disability, substance use disorder, mental illness, PTSD, traumatic brain injury, chronic health issue, intellectual disability, etc.)
Unsure or Prefer not to answer
What source(s) of income do you or people in your household receive?
Earned income from a job
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
No income currently.
What do you need help with? (Check all that apply. Unfortunately, this does not guarantee help.)
Long term housing
Supplies (sleeping bag, propane, etc.)
Talk to a counselor/mental health support
Treatment & recovery support (alcohol/drug use)
Job search connections
Social security disability application
Help with health insurance
Help for school-aged kids
Where do you primarily seek medical care?
Emergency Room or Urgent Care
Bend Memorial Clinic
St Charles Healthcare
High Lakes Healthcare
Indian Health Services
Other Private Doctor
Not connected to medical care.
We respect your privacy and independence. Do you give us permission to share this information with local service providers to connect you with help?*
No (This system relies on sharing information with service providers to get you connected.)
Some people are at risk of getting very sick if they get COVID-19. Are you currently unhoused AND do any of these apply to you: Over age 60? Chronic health conditions? Pregnant?
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