Agency Name
*
Agency Address
*
Name of Referring Provider
*
Provider Email
*
Provider Phone Number
(###)
###
####
Participant Name
*
First Name
Last Name
Participant Email
Participant Phone Number
(###)
###
####
Participant Gender
*
Female
Male
A gender other than singularly male or female (e.g., non-binary, genderfluid, agender, culturally specific gender)
Transgender
Questioning
I'd rather not say
Participant Race
*
American Indian, Alaska Native, or Indigenous
Asian or Asian American
Black, African American, or African
Native Hawaiin or Pacific Islander
White
Other
I'd rather not say
Participant Ethnicity
*
Non-Hispanic/Non-Latin(a)(o)(x)
Hispanic/Non-Latin(a)(o)(x)
I'd rather not say
Participant Date of Birth
*
Is participant a veteran?
*
Yes
No
I'd rather not say
Does participant have any pets?
*
Yes
No
If yes, what type and how many?
Does participant currently reside in Oregon?
*
Yes
No
What city or town does participant currently reside in?
*
Please ask the participant: Where are you currently sleeping? (Tent, vehicle, housed, shelter, hospital, etc.)
*
If unsheltered, please provide cross streets or landmark.
*
How long has participant been sleeping in this location?
*
Can the Participant care for themselves and complete all ADL's (Activities of Daily Living) independently?
Yes
No
Does participant use any mobility devices?
*
Walker
Wheelchair
Cane
Crutches
None
Can participant access a top bunk safely?
*
Yes
No
Single bed or couple bed? (If couple bed please submit a form for the partner as well and include the partners name on each form.)
*
Single
Couple
Any known medical conditions?
*
Any mental health diagnoses or concerns? If yes, are they receiving services?
*
History of SUD? Past or present?
*
Does participant prefer an abstinence-based environment (including from alcohol and marijuana) or low-barrier environment?
*
Abstinence-based environment
Low-barrier environment
Please ask this question to the participant: Do you want to be in a congregate, dorm style shelter? (This form is not for a private room, not a motel shelter, not a tiny home, not housing)
*
Yes
No
Please ask this question to the participant: Are you willing to follow shelter expectations of communal living? (example: getting along with others, being mindful of everyone’s property and space)
*
Yes
No
Does the participant have a way to get to the shelter if offered a bed?
*
Yes
No
Preferred shelter or location?
*
Does this person have a vehicle?
Yes
No
What is the participants preferred language?
When will the participant be ready for shelter?
MM
DD
YYYY
Is there any other information you think we should know?
