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 Date of Birth
Which county do you live in? [Please note: this form is intended only for people who currently live in Central Oregon.]
Deschutes County (for example, Bend, Redmond, La Pine, Sisters)
Crook County (for example, Prineville, Powell Butte)
Jefferson County (for example, Madras, Crooked River Ranch, NOT including Warm Springs)
Warm Springs Reservation
Which city or area do you live in?
Where do you/your family sleep most frequently?
Shelter (for example, Bethlehem Inn)
Transitional Housing (for example, Nancy's House, Grandma's House, Shepherds House, LOFT resident)
Outdoors (for example, tent camping on public land)
In a vehicle (including an RV or trailer without hookups)
Staying with friends or family (for example, couch surfing or doubled up)
In a structure not meant for habitation (for example, a shed or abandoned building)
Not homeless today, but probably will be soon.
How long has it been since you felt like your housing was safe and stable?
Two parent household
Couple, no children
How many adults (age 18 and up) are in your household?
1 (Just me)
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).
Email address (if you check it).
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.]
If someone is helping you fill out this form, please share their name, phone number, and relationship to you.
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.
Just update my contact info.
How do you identify your race?
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.)
Unsure or Prefer not to answer
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.)
What source(s) of income do you or people in your household receive?
Earned income from a job
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
What do you need help with? (Check all that apply. Unfortunately, this does not guarantee help.)
Long term housing
Supplies (sleeping bag, propane, etc.)
Talk to a counselor/mental health support
Treatment & recovery support (alcohol/drug use)
Job search connections
Social security disability application
Help with health insurance
Help for school-aged kids
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.)
Sign me up!
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.)
Prefer not to say.
We respect your privacy and independence. Do you give us permission to share this information with local service providers to connect you with help?*
No (This system relies on sharing information with service providers to get you connected.)
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