5CHC Cabins for Change Program Referral For Wait List
Please complete this form to make a referral to 5CHC's Cabins for Change Program in Grover Beach.  All cabins are currently reserved.  This is an adults only shelter. Only adults who reside in San Luis Obispo County and who are experiencing homelessness may be referred to the program.  Priority status is given to those who reside in South County, as follows:
  • Single Women
  • Transitional Age Youth (18-24)
  • Veteran
  • Disabled
  • Senior Citizen
  • LGBTQ+
Please use the client HMIS number if known.  If using a client name do not include any health information. Email Cabin Supervisor Rachel Perey, shelter@5chc.org to notify her that the form has been submitted. You may text the cabin monitor on site at 805-634-9906 if the request is time sensitive. 

Important: If you have any changes to your contact information or other critical details, it is your responsibility to notify us immediately by texting 805-634-9906 or emailing shelter@5chc.org. Failure to respond after three contact attempts will result in your removal from the waiting list.

If you have any questions contact shelter@5chc.org
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What is the Client's Full Name? 
[Client = Individual Seeking Shelter]
 *
Is the Client Homeless? *
Has the Client consented to have their information released? 
[Signed the 815]
 *
Referral Originated From: *
Name of Person completing this form *
Email of Person completing this form *
Phone number of Person completing this form *
Has the Client been entered into HMIS/Coordinated Entry System? *
What is the Client's HMIS ID? [IF Available] If client has yet to be entered into HMIS type in N/A *
Is the Client currently working with a 5CHC Case Manager?
 *
What 5CHC Case Manager is the Client currently working with? Write N/A if not applicable
 *
What is the Client's Date-of-Birth? *
MM
/
DD
/
YYYY
What is the Client's Primary Community of Residence? *
What is the Client's Gender Identity? *
Required
Does the Client identify themselves as part of the LGBTQIA+ community? *
Does the Client have a disabling condition? *
If the Client has a disability, will they need an ADA accessible cabin? *
Client Phone Number *
Client Email *
What is the Client's Preferred Language? *
Is the Client a Veteran? *
Is the Client currently fleeing Domestic Violence/Abuse? *
Does the Client have a Section 8 Voucher? *
Approximately what date did the Client become currently homeless? *
MM
/
DD
/
YYYY
How many times in the last 3 years has the Client been homeless? *
Does the Client (or Partner) have a dog(s)? *
If the Client (or Partner) has more than one dog, how many do they have? If the Client has one dog or no dogs, type in N/A *
If the Client (or Partner) has a dog(s), are they: *
Yes
No
Unknown
N/A
Registered with the County of San Luis Obispo
Vaccinated (Up to Date)
Registered as a Service Animal
Is the Client seeking a Cabin with Self or With a Partner? [No more than two people to a cabin] *
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