Moutain Homeless Coalition Intake Form

1
Does the person or household requesting help currently reside in the San Bernardino mountains?* This field is required.
YESNO
2
At this time Mountain Homeless Coalition is not able to assist those not living in our service area. We recommend you dial 211 or search Findhelp.org to find agencies in your area that can better help you.
3
To begin, please tell us if you are submitting this request for assistance on behalf of:
Myself / My Household
On behalf of someone other than myself
Other
4
By providing your household information on the following web-based referral form, you are VOLUNTARILY CONSENTING to have the Mountain Homeless Coalition share the information provided by you among other service providers in hopes of finding resources available to help with your housing challenge. You are not required to respond to every question, however doing so will make it easier for us to identify all potential options for your household. If you agree and wish to continue, press the "I AGREE" button.* This field is required.
I AGREENO
5
Release of Information Authorization* This field is required.I agree to allow my responses to this survey to be disclosed and received by the organizations that participate in the San Bernardino County Coordinated Entry System and to be entered into the San Bernardino County Homeless Management Information System. I understand that the information will be used to determine if I am eligible for participating in housing programs, service programs or related programs and will only be used to identify housing opportunities. The confidentiality of my records is protected by law and the Agency will never give information about me to anyone outside the Agency without my consent.
Clear
6
What is your relationship to the subject household?
Mountain Homeless Coalition staff or volunteer
Another Social Service agency or community organization
A family member/friend/neighbor/other
7
Name of organization you represent (if applicable)?
8
Your first and last name
9
Your phone number
Please enter a valid phone number.
10
Your street address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Your E-mail address
example@example.com
12
Do you confirm that an adult member of the household identified herein has given written or verbal consent for you to share the following household information with the Mountain Homeless Coalition to help identify potential housing, shelter or other resources to resolve their housing challenge?
YESNO
13
Today's Date* This field is required.
Date
Month
Day
Year
14
Name* This field is required.
First Name
Last Name
15
Phone Number
Please enter a valid phone number.
16
Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Email
example@example.com
18
What is the best way to contact you?
19
If we are unable to reach you using your phone or email, is there another person we could leave a message with, or another way to contact you?
20
Gender* This field is required.
Male
Female
Transgender
Other
21
Date of Birth* This field is required.
Date
Month
Day
Year
22
Race* This field is required.Choose as many as you like
Asian
Black/African American
Native American/Alaskan Native
Native Hawaiian/Pacific Islander
White/Caucasian
Other
Decline to state
23
Ethnicity* This field is required.
Hispanic/Latino
Non-Hispanic/Latino
24
Are you a veteran?* This field is required.
Yes, I am a veteran
No, I am not a veteran
25
Year entered service: YYYY
Year separated from service: YYYY
Branch of service:
Discharge status:
26
Social Security Number* This field is required.Last four digits are required - full SSN will help us assist you.
27
What is your household status?* This field is required.
Single Adult/no children
2 or more adults/no children
Household w/children under 18 years old
28
Number of adults over 18 years old in your household (including yourself)?
29
Number of children under 18 years old in your household?
30
What are the age(s) of the children under 18 years old in household?Choose as many as you like
0-5
6-12
13-18
Not applicable
31
Do you have children attending school in San Bernardino County?
YESNO
32
Do you have any pets in your household?
YESNO
33
If yes to pets, please identify number and type(s)?
34
In what city or community are you currently living/sleeping?* This field is required.
35
Where did you sleep last night?* This field is required.
Car / Vehicle
Park / Streets
Abandoned building / property
Camping ground / Encampment
Shelter
Hotel/Motel paid by 3rd Party
Hotel/Motel paid by self
Family/friends
Housing
Other
36
How long have you been homeless/at-risk of homelessness?
1 day
1 week
Less than 1 month
1-3 months
4-6 months
7-9 months
10-12 months
1 year or more
Other
37
Where will you sleep tonight?
Car / Vehicle
Park / Streets
Abandoned building / property
Camping ground / Encampment
Shelter
Hotel/Motel paid by 3rd Party
Hotel/Motel paid by self
Family/friends
Housing
Other
38
If necessary, are you willing to relocate outside of the area where you currently live/sleep?
YESNO
39
Do you have a vehicle or source of transportation?
YESNO
40
Do you receive CalWORKS benefits?
YESNO
41
What is your monthly household income amount? required* This field is required.
42
What is your current source of income? (Select all that apply)* This field is required.Choose as many as you like
None
Employment
Self Employment
Cash Aid/TANF
Cal Fresh
Child/Spousal Support
EDD/Unemployment benefits
Social Security Income
Social Security Disability Insurance
State Disability/Workers Comp
Veterans Benefits
Retirement Benefits
Other
43
Are you interested in referrals to employment services at this time?
YESNO
44
Are you currently able to access medical/health care services when needed?
YESNO
45
What is your primary source for medical/health care coverage?* This field is required.
Medi-Cal / Medicare
State Medi-Cal for Families
IEHP
Molina Healthcare
VA Health Care
Employer-Sponsored Health Insurance
Private Pay Health Insurance
I do not currently have health care coverage
Other
46
Please briefly describe your current or pending housing crisis?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
47
What has triggered your current or pending housing crisis? (check all that apply)Choose as many as you like
Pending or recent eviction from rental housing
Fell behind on rent and unable to catch up
Lack of steady income and/or employment
Sudden/significant increase in rent
Sudden/significant loss of household income
Unanticipated financial incident or traumatic event
Living doubled-up / overcrowded with family or friends
Unable to secure affordable rental housing
Spending all available resources to live in motels or other temporary housing
Have continuously lived off and on the streets, with friends, etc. for a year or more
Fleeing / attempting to flee domestic abuse
Dealing with chronic physical health issues
Dealing with mental / behavioral health challenges
Dealing with alcohol and/or drug abuse issues
Other
48
Please identify your current obstacles to achieving housing stability at this time? (check all that apply)* This field is required.Choose as many as you like
No / limited income
Housing affordability
Poor rental history / past eviction(s)
Credit issues
Behavioral health issues
Alcohol and/or drug abuse issues
Chronic health condition(s)
Physical disabilities / challenges
Fleeing / attempting to flee domestic abuse
Other
49
What type of housing assistance are you seeking at this time? (check all that apply)Choose as many as you like
Eviction prevention assistance
Emergency shelter
Hotel/motel stay
Transitional housing
Help finding new rental housing
Rental deposit assistance
Short-term rental subsidy
Substance abuse recovery program
Domestic violence services
Supportive Housing for persons with disabling conditions
Other
50
Do you currently have the household income, and/or a housing voucher in hand, sufficient to rent housing on your own, but face other barriers such as rental history, credit challenges, lack of funds for security deposit, etc.?
YESNO
51
Would you be interested in receiving self-help housing search guidance and rental vacancy leads to assist you with identifying rental housing options that you can afford with your own resources with no, or a limited amount of, additional assistance?
YESNO
52
Which statement below best describes your current living situation? required* This field is required.(please review all choices before making your selection)
currently fleeing or attempting to flee domestic abuse / intimate partner violence
"literally homeless" - currently sleeping in car, park, abandoned property, or other places not meant for regular human habitation.
staying in emergency shelter or other short-term housing
staying in hotel/motel paid by government or charitable organization
paying to stay in hotel/motels with my own resources
temporarily living with family or friends
facing loss of rental housing leased in my name
facing loss of room for rent from third party renter/owner or shared living home
exiting time-limited transitional housing
exiting an institutional facility
Other
53
How long in your living situation?* This field is required.
1 day
1 week
Less than 1 month
1-3 months
4-6 months
7-9 months
10-12 months
1 year
Other
54
If you are homeless, what is the number of times on the streets or in emergency shelter in the past three years?* This field is required.
1 time
2 times
3 times
4 or more times
I'm not homeless
55
If you are homeless, what is the total number of months homeless, on the streets or in an emergency shelter in the past three years?* This field is required.
1 month (this is the first month)
5 months
2 months
6 months
3 months
7 months
4 months
8 months
9 months
10 months
11 months
12 or more months
I am not homeless
56
If you are homeless, what is the approximate date (or month/year) of the last time you had a place to sleep that was not on the streets, in an emergency shelter or motel paid by a third party?
57
Do you have the option to remain at your current living situation until you can secure housing on your own?
YESNO
58
If you must leave your current living situation, by what date do you have to vacate?
Date
Month
Day
Year
59
If you must leave your current living situation, do you have family, friends, or other options available for a temporary place to stay until you can secure new housing on your own?
YESNO
60
Where might you go if you have to leave your current living situation?* This field is required.Choose as many as you like
outdoor location or other place not meant for regular sleeping accommodations such as car, park, abandoned property, etc.
emergency shelter or other short-term facility
stay with family or friends
hotel/motel paid by an organization or other third party
pay for hotel/motel with my own resources
new rental housing leased in my name
leave the area
I don't know
Other
61
Please check all categories below that apply to you and/or members of your household:* This field is required.Choose as many as you like
Continuously Homeless for 1 year or more
Homeless 4 different times in last 3 years
Military Veteran
Transitional Aged Youth (18-24)
Have been in foster care
Senior (62+)
Mental Health Condition
Chronic Health Condition
Physically Disabled
Developmental/Intellectual Disability
Dealing w/Substance Abuse Issues
Living with HIV/AIDS
Currently on Parole or Probation
Domestic Violence/Abuse Survivor
Single parent w/children under 18
Pregnant
None of the above
Other
62
Is the health or disabling condition identified expected to be long continuing or of indefinite duration and substantially impede your and/or your household’s ability to live independently.
YESNO
63
Would you be interested in considering a shared housing / cooperative living arrangement if such an option is available for your household?
YESNO
64
Please provide any additional comments or information that you think might help with identifying referral options for your household. For example, who else have you contacted for assistance?
65
What agency and/or person referred you to the Mountain Homeless Coalition?
Should be Empty: