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SOHRAD Service Provider Referral Form
Street Outreach and Harm Reduction Deflection Program
Are you concerned about someone living unsheltered in our community?
Completing this form is optional.
*Referrals can also be made by calling (919) 886-3351 or emailing
SOHRAD@orangecountync.gov
*
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* Indicates required question
Service Provider Name
*
Your answer
Service Provider Phone Number
Your answer
Service Provider Email
Your answer
What is the age of the person you are referring
Choose
18-24
25-34
35-44
45-54
55+
Is the individual currently living unsheltered? (i.e. residing in a place not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings, on the street)
*
Choose
Yes
No
I'm not sure
Which best describes how the individual you are referring self-identifies?
Choose
Cisgender
Transgender
Other
Prefer not to answer
Which best describes how the individual you are referring self-identifies?
Choose
Male
Female
Non-binary/Gender Nonconforming
Other
Prefer not to answer
Which best describes how the individual you are referring identifies their race/ethnicity?
Choose
Asian or Pacific Islander
Black or African-American
Hispanic or Latino
White or Caucasian
Multiracial or Biracial
Prefer not to answer
Other
Is the individual you are referring already working with a provider, and if so who? (i.e. housing supports, mental health provider, etc.)
Your answer
Is there any contact information for the individual you are referring? (i.e. phone number, email address, location last seen)
*
Your answer
Any other information the SOHRAD Team may find helpful
Your answer
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