Single Adults Aged 25+

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Did you or someone you know who is a single adult aged 26 or older sleep in one of the following locations 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.

Individual's first and last name (and nickname, if applicable)

Individual's date of birth

YYYY

Individual's gender

Female

Male

Unknown/Prefers not to say

Other:

Clear selection

Individual's race and ethnicity (select all that apply)

Black/African American

White/Caucasian

Hispanic/Latinx

Native/American Indian

Asian/Pacific Islander

Unknown

Please provide a brief physical description of this individual.

Example: "Shoulder-length, brown, curly hair; green eyes; freckles on skin; not very tall (about 5 ft); average build, tattoo on left forearm."

Where did this individual sleep last night?

Where does this individual adult sleep most frequently?

NOTE: Persons experiencing homelessness may sleep in multiple places while homeless. This question is asking where this person 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 individual 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 person who moved in with their friend “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 person can return to every day without fear of being locked out, or having to move frequently. It is housing that the person feels comfortable enough saying it is their home.

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

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

Once (this time)

2 - 5 times

6 or more times

Unknown

Clear selection

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

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

Which, if any, identifying documents does this individual have/have access to? (select all that apply)

State-issued ID

Social Security Card

Birth Certificate

Unknown

Other:

Does this individual have any of the following resources? (select all that apply)

Health Insurance (including Medicaid)

Transportation

Income from any source (job, government, allowance, etc.)

Unknown

Other:

This individual 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

None

Other:

Is this individual currently receiving any sort of supportive services? Please provide details.

Examples: basic needs assistance, transportation assistance, free and low-cost medical care, tutoring, etc.

Would this individual like assistance?

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

Unknown

Clear selection

What is the best way to contact this individual?

Please list this individual's contact information and preferred contact method (call, text, email, etc.)

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

Is there anyone we can contact regarding this individual 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 individual or their current situation?

Submit

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