Coalition for the Homeless of Central Florida

Program Description

Program Description: The Coalition's goal is to restore hope by helping individuals and famlies find their way home. Today you can expect to meet with a Crisis Case Manager for 30 minutes or longer to work with you during your housing crisis. Thank you for your patience while we ensure that every person and family's needs are met. While you are waiting, please complete this triage form. Thank you!

Demographic Questions:

Demographic Questions:

Name:

Date of Birth:

Today's Date:

Phone Number:

Email:

Social Security Number:

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

Are you a United States Citizen?

Yes

No

If no, what is your status?

Did you ever serve in the military?

Yes

No

If yes, did you serve active duty?

Who referred you to the Coalition?

Marital Status:

If other:

Emergency Contact Name:

Emergency Contact Relationship

Emergency Contact Phone Number:

Residency Questions:

Residency Questions:

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?

Where was your last permanent address?

When did you live there?

What is the cause of your homelessness?

What services are you seeking today?

Are you currently working with another agency for assistance?

Yes

No

If yes, please indicate what agency

Do you have an Orange County ID?

Yes

No

Income & Insurance Questions:

Income & Insurance Questions:

Do you have any income? (i.e. employment, SSI/SSDI, TANF, VA pension)

Yes

No

If yes, what is the source?

How much is it per month?

Do you have Food Stamps (SNAP/EBT)?

Yes

No

If yes, how much do you receive per month?

Do you have health insurance?

Yes

No

If yes, what kind is it?

Domestic Violence:

Domestic Violence:

Do you have any questions regarding Medicare, Medicaid, or Disability?

Yes

No

Are you a domestic violence victim/survivor?

Yes

No

Are you currently fleeing?

Yes

No

If so, when did the last experience occur?

Household Questions:

Household Questions:

Household Table

Disability Questions:

Disability Questions:

Please mark if you experience any of the following disabilities:

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

Coalition Triage Form: Diversion and Emergency Services

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