Agency Name
Agency Address
Name of Referring Provider
Email
Phone Number
(###)
###
####
Name
*
First Name
Last Name
Email
*
Phone Number
(###)
###
####
Gender
*
Female
Male
Non-binary, genderfluid, agender, culturally specific gender
Trans Woman
Trans Man
Questioning
I'd rather not say
Race
*
American Indian, Alaska Native, or Indigenous
Asian or Asian American
Black, African American, or African
Native Hawaiin or Pacific Islander
White
Other
I'd rather not say
Ethnicity
*
Non-Hispanic/Non-Latin(a)(o)(x)
Hispanic/Non-Latin(a)(o)(x)
I'd rather not say
Date of Birth
*
MM
DD
YYYY
What is your preferred language?
*
Do you currently reside in Oregon?
*
Yes
No
What city or town do you currently reside in?
*
Where are you currently sleeping? (Tent, vehicle, housed, shelter, hospital, etc.)
*
If unsheltered, please provide cross streets or landmark.
*
How long have you been sleeping in this location?
*
Do you consider yourself to be disabled?
*
Yes
No
I'd rather not say
Do you use any mobility devices?
*
Yes
No
I'd rather not say
If yes, what type of device do you use?
Do you have any known medical conditions?
*
Yes
No
Do you have any known mental health concerns?
*
Yes
No
If yes, are you currently receiving services?
Do you have any history of substance use?
*
Yes
No
If yes, is it past or present?
Can you care for yourself independently?
*
Yes
No
Do you have any pets?
*
Yes
No
If yes, what kind and how many?
Are you a veteran?
*
Yes
No
I'd rather not say
Can you access the top bunk safely?
*
Yes
No
I'm not sure
Do you have any medical conditions that prevent you from accessing a top bunk safely?
*
Yes
No
I'm not sure
Shelters do not allow bed moves. Do you acknowledge this policy?
*
Yes
No
Do you prefer an abstinence-based environment (including from alcohol and marijuana) or a low-barrier environment?
*
Abstinence-based environment
Low-barrier environment
No preference
Not sure
Do you have a preferred shelter location?
*
Are you interested in going to a congregate, dorm style shelter? (This form is not for a private room, not a motel shelter, not a tiny home, and not for housing)
*
Yes, I am okay with a congregate, dorm style shelter
No
Are you willing to follow shelter expectations of communal living? (example: getting along with others, being mindful of everyone’s property and space)
*
Yes
No
Do you have a way to get to the shelter if offered a bed?
*
Yes
No
Do you have a vehicle?
*
Yes
No
What date will you be ready for shelter?
*
MM
DD
YYYY
Is there any other information you think we should know?
