Coalition for the Homeless of Central Florida

Program Description

Please complete this short form so our Intake and Diversion team can better understand your situation and help determine the next steps.

Demographic Questions:

Demographic Questions:

Name:

Date of Birth:

Today's Date:

Phone Number:

Email:

Gender:

Male

Female

Transgender: presents as female

Transgender: presents as male

Race (check all that apply):

Ethnicity

Hispanic or Latino

Non-Hispanic or non-Latino

Did you ever serve in the military?

Yes

No

If yes, did you serve active duty?

Marital Status:

If other:

Who is seeking assistance?

Myself

My family/household

If family/household, please list name and ages:

Current Housing Situation

Current Housing Situation

Where did you sleep last night?

Outside or in a vehicle

In a shelter

With friends or family

In a hotel or motel

In my own housing

Other / Prefer not to say

How long did you stay there?

What is the cause of your homelessness?