Families

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Families

Did your family or a family you know sleep in any of the following places last night?

Slept in an uninhabitable public or private place such as a car, tent or outdoors; or
In a publicly or privately operated shelter; or
In a hotel or motel paid for by charitable organizations or by federal, state and local government programs; or
Is fleeing domestic violence

If so, please complete this referral form to the best of your ability for further assistance from the West Texas Homeless Network.

Referrer's first and last name

NOTE: If you are completing this referral for yourself, please skip this question.

Referrer's agency and/or location (city, state)

NOTE: If you are completing this referral for yourself, please skip this question.

Referrer's phone number

NOTE: If you are completing this referral for yourself, please skip this question.

Head of family's first and last name (and nickname, if applicable)

Head of family's date of birth

YYYY

Head of family's gender

Female

Male

Unknown/Prefers not to say

Other:

Clear selection

Head of family's race and ethnicity (select all that apply)

Black/African American

White/Caucasian

Hispanic/Latinx

Native/American Indian

Asian/Pacific Islander

Unknown

Number of adults in this household

Number of children ages 0-17 in this household

Where did this family sleep last night?

Where does this family sleep most frequently?

NOTE: Persons experiencing homelessness may sleep in multiple places while homeless. This question is asking where this family has slept most often throughout the duration of their current episode of homelessness.

In a car, tent, or outside

In a building without heat/AC or running water

In an emergency shelter

In a hotel or motel

Somewhere fleeing domestic violence

Unknown

Other:

Clear selection

Approximately how long has it been since this family has lived in permanent, stable housing?

This question is interested in the duration of their current episode of homelessness. “Permanent, stable housing” has two components:

Permanent housing is housing that is not temporary (i.e., there was no time limit imposed on this person's stay). A family who moved in with their friend or non-immediate family member “until they could find another place” is considered temporary. If they lived in a friend's spare room, shared rent, and the friend was okay with them living there indefinitely, the situation is considered permanent.
Stable housing is housing that is reliable and that the family can return to every day without fear of being locked out, or having to move frequently. It is housing that the family feels comfortable enough saying it is their home.

If the head of family is unsure, ask if they felt it was a permanent and stable.

In the past 3 years, how many times has this family experienced housing instability?

Once (this time)

2 - 5 times

6 or more times

Unknown

Clear selection

What led to this family's current episode of housing instability?

Please provide as many details as they are willing/able to share.

This family has reported the following concerns and/or potential housing barriers (select all that apply):

Mental health

Physical health

Substance use/misuse

Legal issues

Abuse of any kind

Other:

Would this family like assistance? *

This family declines this referral to housing assistance and the referrer has provided them with the West Texas Homeless Network's contact information in case they change their mind.

This family would like assistance and gives the referrer listed above permission to release information regarding this family's housing situation to the West Texas Homeless Network (WTHN) for housing purposes. By selecting this option, this family permits WTHN and its housing partners to contact this family to further assess their needs for housing purposes.

Unknown

What is the best way to contact this family? *

Please list the name, contact information, and preferred contact method (call, text, email, etc.)

Where is the best place to find this family if they cannot be contacted with the information provided?

Is there anyone we can contact regarding this family in case of an emergency? If so, please list their name, relationship to the individual, and contact information.

Is there any other information that you would like to share in regard to this family or their current situation?

Submit

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