Street Outreach Intake Form
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First Name
Last Name
Phone Number
Email address
Date of Birth
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Race
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 Ethnicity
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Gender
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Does client  have a disabling condition?
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If yes, disability type
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Does the Client have Health Insurance?
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If yes, what type of Health Insurance does the Client have?
Relationship to Head of Household
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Prior Living Situation
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Length of Stay in Previous Place
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Approximate date homelessness started
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DD
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Regardless where they stayed last night, number of times the client has been on the streets, in ES, or SH in the past three years including today.
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Referral Source:
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Contact Person's Name
Contact Person's Phone Number
Total number of months homeless on the street, in ES or SH in the past three years.
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Zip Code of Last Permanent Address
Cause of Homelessness/Housing Crisis
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Income from Any Source
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County
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Submit
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