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Street Outreach Referral for Literally Homeless Persons
If a homeless individual is in need of homeless services, including emergency shelter, they should call the Homeless Hotline at 1-888-731-0999. Call 911 for health or police emergencies.
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Please complete this form with whatever information is known. Any information is helpful. If you have any questions, call or text John Harrison at 240-270-2408.
Referral Source (Organization)
*
Your answer
Referral Source - Contact Name
*
Your answer
Referral Source - Telephone number
Your answer
Referral Source - Email
Your answer
Date of contact with client
MM
/
DD
/
YYYY
Time of contact with client
Time
:
AM
PM
Client First Name
Your answer
Client Middle Initial
Your answer
Client Last Name
Your answer
Client Age
Your answer
Client Date of Birth
MM
/
DD
/
YYYY
Number in Household
Your answer
Contact Location (or where the client sleeps) - Address, Intersection, Business, or Nearest Landmark
Your answer
Client contact information - Phone or Email
Your answer
Primary Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Client Refused
Other:
Clear selection
Ethnicity
Hispanic/Latino
Non-hispanic/Non-Latino
Client Refused
Clear selection
Gender
Female
Male
Non-binary (not exclusively male or female)
Prefer not to say
Other:
Clear selection
Transgender
Yes
No
Prefer not to say
Other:
Clear selection
Military Service
Yes - Active Duty
Yes - Basic Training
Yes - Reserve/National Guard
No
Other:
Clear selection
Disabilities
Your answer
Where did client sleep last night?
Outdoors
Vehicle
Emergency Shelter
Couch Hopping
Staying with Friends or Family
Hotel - Self Paid
Hotel - Paid by an organization
Other:
Clear selection
Length of homelessness - This time
Your answer
Length of homelessness - Longest time
Your answer
Services the client needs
Emergency shelter
Mental health referral
Physical health referral
Mailing address
Photo ID
Social Security Card
Birth Certificate
Help with benefits
Other:
Is anyone assisting the client right now for any services (therapist, veteran, housing, benefits, food stamps, etc.)
Your answer
Other notes or observations
Your answer
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