Homelessness to Housing supports intake

Single point of intake

Eligible clients: newly housed homeless people

Delivery is being provided by Habitat for Humanity and we wish to co-ordinate all deliveries into one single drop off.

Drop offs will be at the outside door of the building, recipients will be expected to bring their goods inside and set up their bed themselves.

Bedding colours will be restricted by what is available, it is more helpful to include what they HATE as much as it is what they'd love. Bedding is a basic 'bed in a bag' from Walmart.

Not for people experiencing disaster or bed bugs etc.

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* 1. Referring Agency contact information

Name

Company

Email Address

Phone Number

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* 2. Client contact and delivery information

Name

Address

Address 2

City/Town

County

Email Address

Phone Number

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* 3. Mattress size for adult(s)

Double

Twin

other - need an explanation for other sizes

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* 4. Twin mattress or mattresses for children

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 5. Is bedding needed for all mattresses?

Yes

Other (please specify)

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* 6. Bedding colour suggestions:

Bed one (largest bed)

Bed two

Bed three

Bed four

Bed five

Bed six

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* 7. Is a "home starter kit" required at this time? (one per household)

Yes

Other (please specify)

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* 8. Data question for reporting requirements

How many in the household

Number of seniors

Number of adults

Number of youth (under 18)

Main income source

Homelessness to Housing supports intake

Single point of intake

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* 1. Referring Agency contact information

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* 2. Client contact and delivery information

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* 3. Mattress size for adult(s)

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* 4. Twin mattress or mattresses for children

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* 5. Is bedding needed for all mattresses?

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* 6. Bedding colour suggestions:

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* 7. Is a "home starter kit" required at this time? (one per household)

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* 8. Data question for reporting requirements

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* 9. Anything else we need to know