Referral for Homeless Outreach Services

**Please note this is NOT a form for self-referral. If you, your family, or someone you know well is experiencing homelessness, please call the Urban Ministry Center main line at 704-347-0278 or visit us at 945 North College Street; Charlotte, NC 28206.**

In what location do you typically see the person? Please be as specific as possible, keeping in mind that your details will make a difference in our ability to find the person you are referring

Example: Go to the corner of 5th & Smith Street. You'll see a red restaurant on the corner. There is a camp about 50 feet behind the restaurant that is not visible from the road.

This is a required question

Description of person (please include gender, race, age, and any identifying features)

Example: Caucasian female, probably between 30-45 years old, has short blonde hair. Usually wears a green sweatshirt.

This is a required question

How often have you seen the person at this location and what time do you typically see them?

Example: I see him a few times a week during the weekday, usually between 5-6 PM. I started noticing him at this location in February.

This is a required question

Do you know the person's name? If so, please provide it.

Example: Yes, her name is Cindy.

This is a required question

Is there any other information you would like to share about the person you're referring?

Example: Sometimes appears to be talking to himself and he declined my offer of food.

This is a required question

We are requesting the following information in case we need to follow up with you about your referral.

We will not expose your information unless you specify that you'd like us to do so. You can expect a personal email within 2 business days of form submission to verify we received your submission, but in order to protect confidentiality, we will likely be unable to provide more information about our interaction with the individual.

What is your name?

This is a required question

Please list your contact information (email and/or phone).

This is a required question