Welcome to our community’s Coordinated Entry. The information provided on this form will help us determine if youare eligible for Coordinated Entry. Upon receipt, you will be contacted regarding your eligibility. If you are eligible, anIntake appointment will be scheduled. If you are not, we will discuss the reasons for this determination and provideyou with information on other resources that may be able to assist. If you have not received a response from us within10 business days of submission, or if you need help completing this form, please contact us.

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Pre-Screening Form

Name
Are you a Veteran?
Are you currently fleeing domestic violence?
Gender
Is there anyone else in your household? This may be an adult or child who is not currently living with you, but would live with you if you had housing.

Adult

Name
Veteran

Adult

Name
Veteran
Only list children who are now, or would be if appropriate housing was obtained, in your legal custody.
Child's Name
Attending school?
Child's Name
Attending school?
Child's Name
Attending school?
Attending school? (copy)
Child's Name
Attending school?
Is anyone listed above, disabled?
Where did you, and the other members of your household, sleep last night? Write the initials of each household member next to the place they slept. If all members of the household resided in the same place, you may indicate this by writing “ALL” by this location.
IF YOU ARE STAYING IN THE RESIDENCE OF ANOTHER PERSON OR IN A RESIDENCE YOU RENT/ OWN...Have you been told by the person with whom you’re staying, or received a court ordered eviction, indicating you must leave within the next two weeks?