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PCHO Housing and Outreach Inquiry Form
Thank you for your interest in PCHO. Please fill out this form as completely as possible. Please make sure you have a phone number or a location listed that an outreach worker can locate you to do an in person referral if you qualify. Someone should reach out to you within 2 business days.
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Email
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Your email
Date:
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MM
/
DD
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YYYY
First Name:
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Your answer
Last Name:
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Your answer
Preferred Language:
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Your answer
Phone:
Your answer
Are you homeless (Street, emergency shelter, transitional housing, fleeing domestic violence) or at risk of homelessness?
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Your answer
Where did you stay last night?
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With a friend/family member/or other doubled up situation.
In my own housing - rental
In my own housing - owned
A hospital
Jail/prison
Juvenile detention facility
Hotel/Motel
In a foster care/group home/halfway house
In a substance use treatment facility
In a car, on the street, or in another place not meant for human habitation.
Emergency Housing/Shelter
Other:
Please describe location you are staying or where we can find you within 24-48 hours
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Your answer
How long do you expect to be at this location so we can reach you?
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Your answer
Is there a best time of day to contact you or find you?
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Your answer
Do you have a place you frequent to eat or spend time (i.e. Asbury Church, St. Joe's, Salem Church, Self-Help Drop-in Center, Blessed Sacrament)?
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Your answer
Do you have a care manager that you work with?
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Your answer
Notes/Comments:
Your answer
Send me a copy of my responses.
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