Bridge2Services – Homeless Database

First Name*

Middle Name*

Last Name*

Best Location to Find You

Date of Birth*

Email Address*

Phone Number

Do you have alternative contact information in case your phone/email doesn't work, such as a family member or friend?

Do you have access to a phone or a computer?*

Yes
No

What caused you to become homeless?*

If other was selected, please describe:

How long have you been homeless?*

What has your living situation been like the last 6 months?

How do you get to important appointments?

What do you usually do for meals?

Do You Have A Source of Income?*

Job
SSI/Disability
Friends/Family
Social Security
Food Stamps/EBT
Medical care
Other

If "other" was selected, please describe:

Are You Currently Working?*

Yes
No

If so, what type of work?

If not, please describe why?*

Do you have a support system (family/friends/etc.)?*

Yes
No

Please describe:

Would you be willing to tell the City/County council your story?

Yes
No

What are your main barriers to getting housing?

Do you have a medical condition?*

Yes
No

If yes, please describe:

Do you have dental needs?*

Yes
No

If yes, please describe:

Do you need help with mental health?*

Yes
No

If yes, please describe:

Do you need help with addictions?*

Yes
No

If yes, please describe:

Do you have a history of personal abuse or trauma?*

Yes
No

Please describe:

Do you need help with any legal issues?*

Yes
No

Please describe:

Are you a Veteran?*

Yes
No

Where did you serve? How many years?

What are 3 things that you want to change in your life? (Long-Term and Short-Term)

Did somebody refer you to Bridge2Services?

Do You Have A Case Manager or Advocate?

Opportunity Council
HOT Team
GRACE
Serenity Outreach Services (SOS)
Road2Home
Base Camp
HomesNOW!
Other
None

Please describe:

Have You Applied for a Tiny Home?

Yes
No

Were You Approved?

Yes
No

Please describe:

Additional Comments

CAPTCHA

Bridge2Services – Homeless Database

Bridge2Services - Homeless Database