PCHO Outreach Inquiry Form

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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.

Email *

Date:

YYYY

First Name: *

Last Name: *

Date of Birth

YYYY

Preferred Language:

Phone:

Are you homeless (Street, emergency shelter, transitional housing, fleeing domestic violence) or at risk of homelessness?

Where did you stay last night?

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:

Clear selection

Please describe location you are staying or where we can find you within 24-48 hours

How long do you expect to be at this location so we can reach you?

Is there a best time of day to contact you or find you?

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)?

Do you have medicaid?

Yes

Maybe

Clear selection

Do you have a care manager that you work with?

Do you have any chronic health, mental health or substance use conditions? (Please describe)

Notes/Comments:

Referral Source and Contact Information

Submit

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