Coordinated Entry Intake
Coordinated Entry is a streamlined system designed to efficiently match people experiencing homelessness or those at-risk of homelessness to available housing, shelter, and services. It prioritizes those who are most in need of assistance and provides crucial information that helps the Continuum of Care strategically allocate resources.
Are you homeless?
Clear selection
Which service are you seeking today?
Clear selection
First Name *
Last Name
Email *
Phone Number *
Date of Birth *
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Are you a resident of Collier County? (Resident status is 6 months or longer) *
What area of the county do you live in?
Clear selection
Are you a Veteran?
Clear selection
Household Type?
Clear selection
Where do you/your family sleep most often? *
How long as it been since you felt like your housing was safe and stable?
Clear selection
How many children (below 18) live in your household?
Your gender
Your race
Clear selection
Your ethnicity
Clear selection
Do you have a disability?
Clear selection
Does someone in your household have a disability?
Clear selection
Does everyone in your household currently have health insurance?
Clear selection
What is your current household income per month?
Are you currently fleeing domestic violence?
Clear selection
We respect your privacy - do you give us permission to share this collection information with local service providers to connect you with help?
Clear selection
COVID 19 Add on questions for Coordinated Entry Intake
Are you currently experiencing symptoms consistent with COVID 19? (fever, cough, shortness of breath)
Clear selection
When did your symptoms begin?
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When did you begin isolation?
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When did you begin your quarantine?
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If hospitalized, what date were you admitted to the hospital?
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If known, what is the COVID-19 test result or confirmed disease status?
Clear selection
If tested for COVID-19, when were you tested?
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If tested for COVID-19, what date were the test results provided to you?
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What is your current symptomatic disposition?
Clear selection
What is the date of your current symptomatic disposition?
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Clinical Health Notes:
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This form was created inside of Collier County Hunger & Homeless Coalition.