Coalition for the Homeless of Central Florida

Client (HMIS ID#)

Today's Date:

Client Name (First & Last):

Client Date of Birth:

Client Gender:

Male

Female

Transgender: presents as female

Transgender: presents as male

Client Phone Number:

Client Email:

Client Race (check all that apply):

Client Ethnicity:

Hispanic or Latino

Non-Hispanic or non-Latino

Are you a United States Citizen?

Yes

No

Status pending

Did you ever serve in the military?

Yes

No

If yes, did you serve active duty?

Marital Status:

If other:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone Number:

Residency Questions:

Residency Questions:

Are you currently housed or homeless?

Yes

No

If you are currently homeless:

Individual (homeless)

Family (homeless)

Where did you stay last night?

How long did you stay there?

What's the address or intersection?

Where did you sleep when you were last housed?

Do you have an Orange County ID?

Yes

No

Income & Insurance Questions:

Income & Insurance Questions:

Do you have any income?

How much is it per month?

Do you have health insurance?

Domestic Violence:

Domestic Violence:

Are you a domestic violence victim/survivor?

Yes

No

Are you currently fleeing?

Yes

No

Disability Questions:

Disability Questions:

Please mark if you experience any of the following disabilities:

Did the COVID-19 Pandemic effect your housing stability in any way?

Yes

No

Below, write any additional information that may be important for us to know:

Referring Case Manager (First & Last):

Referring Case Manager (Phone Number):

Referring Case Manager (Email):

Crisis Outreach: Intake/Referral

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