Coordinated Entry System Intake 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 *
Your answer
Last Name *
Your answer
Your Date of Birth *
MM
/
DD
/
YYYY
Which county do you live in? [Please note: this form is intended only for people who currently live in Central Oregon.] *
Which city or area do you live in? *
Your answer
Where do you/your family sleep most frequently? *
How long has it been since you felt like your housing was safe and stable? *
Your answer
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).
Your answer
Email address (if you check it).
Your answer
Is there a friend, family member, or case worker who could get a message to you if we can't reach you? [Please share their name, phone number, and relationship to you.]
Your answer
If someone is helping you fill out this form, please share their name, phone number, and relationship to you.
Your answer
Check this box if you have filled out this form before and you are just updating your contact information. You do not have to do the rest of this form.
Your Gender:
Your answer
How do you identify your race?
Your answer
Are you Latino or Hispanic?
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.)
Do you and ALL members of your family currently have health insurance that can be used here?
What is your household's monthly income? (a rough guess is okay. Don't include food stamps.)
Your answer
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.)
Your story is important! Please check this box if you would like to learn how you can help us get more housing and services in Central Oregon.
Would you like to subscribe to The Homeless Leadership Coalition’s email newsletter about events, policy issues, and local news stories about housing and homelessness? (You can opt out anytime.)
Are you currently fleeing domestic violence or trapped in an unsafe situation? (Answering "yes" will bring you to a page with resources- your information will be kept confidential.) *
We respect your privacy and independence. Do you give us permission to share this information with local service providers to connect you with help?* *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy