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 privacy and independence are important to us. Information about the HLC privacy policy is at the bottom of this page.
First Name *
Last Name *
Your Date of Birth *
Which city or area do you spend the majority of your time? *
Where do you/your family sleep most frequently? *
How long has it been since you felt like your housing was safe and stable? *
Household type: *
How many adults (age 18 and up) are in your household? *
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?
Your Gender:
How do you identify your race?
Are you Latino or Hispanic?
Clear selection
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.) *
What source(s) of income do you or people in your household receive?
What do you need help with? (Check all that apply. Unfortunately, this does not guarantee help.)
Where do you primarily seek 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?* *
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? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy