Chelan Douglas Coordinated Entry

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Targeted Eligibility Screening

Full Name *

Date of Birth

YYYY

Are you between the ages of 18-24?

Yes

Clear selection

Phone Number

If no phone or email available, what other way can we contact you to follow-up?

Is the applicant Spanish speaking only? *

Yes

Required

Are you a Veteran? *

Yes

Are you a resident of Chelan or Douglas County? *

Yes

Other:

If No, are you fleeing your previous location due to safety concerns?

Yes

Clear selection

Services being requested today? What are your needs? *

What led to your current housing crisis?

Where did you stay last night? *

Housing Status - Check which box(s) applies to you:
*

Currently staying in an emergency shelter, transitional housing, or hotel/motel paid by a charitable organization or government program

Currently staying in a car, park, abandoned building, bus/train station, airport, campground, or on the street

Exiting an institution where you have resided for 90 days or les and were homeless before entering the facility (i.e. healthcare / rehab facility, correctional facility)

Fleeing or attempting to flee domestic violence, intimate partner violence or stalking

Afraid to return to your primary residence

Being harmed or receiving threats of harm

Renting a house or an apartment and facing eviction within 14 days

Facing foreclosure in an owner-occupied property

Exiting a publicly funded institution or system of care (hospital, jail, inpatient treatment, etc) where you've been staying for more than 90 days

Living in a hotel / motel

Staying with friends / acquaintances or family in an unstable situation

Renting or staying with friends or family in a stable situation

Required

In order to use this application, the local agencies in your county will receive this information only if you qualify for a referral, is this okay?

Yes

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms